APPOINTMENT REQUEST FOR PATIENT EVALUATION & RECOMMENDATION

Please provide the following information:
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Please Indicate Your Residency Status in Florida
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If Answered "Medical conditions of the same kind or class" or "Other," Please Select Below. 
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PAYMENT INFORMATION

*Note: Your credit card will not be charged until your appointment is confirmed. Please allow at least 24 hours to be contacted by our staff. 

APPOINTMENT TIMES

no same-day appointments

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Please note, this is only a preferred appointment time. This does not guarantee the selected appointment time. Our Staff will reach out to confirm the selected time or let you know what else is available. 
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How Did You Hear About Us?
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CANCELLATION POLICY

We strive to deliver the best possible service to our patients. If you wish to cancel your appointment, we require a minimum of 48-hours notice. If you cancel your appointment <48 hours of your designated appt time/no show, there is a $50 fee.