Contact Info Form

Please fill out and submit this form at least 48 hours prior to your intial appointment. Required fields are marked with a red asterisk. The information you provide is held as private and will not be shared without your expressed permission. There is no need to resubmit this form at a later date unless your contact information needs to be updated.
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    Please choose all that apply. I do schedule weekend appointments for emergency and acute cases, when needed.