Please provide the following information: Address Changed Recently? YES NO What Conditions Do You Suffer From? AIDS Amyotrophic Lateral Sclerosis Cancer Chronic Nonmalignant Pain Crohn's Disease / IBD Epilepsy Glaucoma Medical conditions of the same kind or class Multiple Sclerosis Other Parkinson's Disease Positive HIV Status PTSD Terminal Condition If Answered "Medical conditions of the same kind or class" or "Other," Please Select Below. Other Medical Conditions that qualify* ADHD Alcoholism Alzheimer's Disease Anorexia Anxiety Arthritis (Autoimmune, Osteo, Other) Asperger Syndrome Autism Cerebral Palsy Chemotherapy Side Effects Dementa (other) Depression Diabetes Dystonia Endometriosis Fibromyalgia Essential Tremor Hepatitis Hyperemesis Colitis Insomnia Irritable Bowel Syndrome Lyme Disease Meniere's Disease Migraines Mood Disorder Myasthenia Gravis Nausea Neuropathy Obesity OCD Ovarian Cysts Psoriasis Radiation Therapy Side Effects Restless Leg Syndrome Rheumatoid Arthritis Seizures Sickel Cell Anemia Spinal Cord Injury Tardive Dyskinesia TMJ Tourette's Traumatic Brain Injury Vertigo Preferred Appointment Time 12:00pm 12:30pm 1:00pm 1:30pm 2:00pm 2:30pm 11:00am 10:30am 10:00am 11:30am Please note, this is only a 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. preferred Preferred Appointment Location North Miami Location Patient Status? First Time Patient Existing Patient Transfer Patient Any of the Above Inquiring About Special Services/House Call
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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. I agree to the terms & conditions Submit