In case of an emergency where you are not present, please authorize an amount for initial evaluation, treatment, and/or stabilization during crisis.(Required)

Please note, this minimum emergency visit may be $500-$1000 in the first few hours. You will be held financially responsible.

Our staff will gladly prepare a written estimate if fees at your request.
We accept the following forms of payment: Cash, Checks (valid driver’s
license required), MasterCard, Visa, Discover Card, American Express, and
Care Credit Card.

All Fees must be paid in full at time of service.

Signature of person responsible for payment:(Required)

I am signing to agree that all the information is correct.

Expires 5 years from signature date.

New Client

New Client Form