Multi Step Checkout “Consultation Fee” has been added to your cart. View cart 1 Step 1 2 Step 2 3 Checkout Step 1 Billing details Payments Billing details Consent and Acknowledgement I acknowledge that the information provided above is accurate to the best of my knowledge. I understand that this information will be used by the medical staff to provide me with appropriate care. I have read and agree to the informed consent agreement. * Step 2 Additional information Personal Information: Full Name * Date of Birth * Gender * MaleFemaleNon-BinaryOtherPrefer not to Answer Address * City * State * Zip Code * Phone Number * Email * Emergency Contact Information Full Name * Phone Number * Medical Information (optional) Primary Care Physician (if any): Reason for Visit (optional) Date of Last Physical Exam * Previous Medical History * Current Medications (Include dosage and frequency) (optional) Allergies (Medications, Food, Environmental) (optional) Past Surgeries/Hospitalizations (optional) Family Medical History (Include any relevant conditions) (optional) Social History (Tobacco use, Alcohol use, Recreational drug use) (optional) Exercise Habits (optional) Checkout Your order Your order Product Subtotal Consultation Fee × 1 $75.00 Subtotal $75.00 Total $75.00 Sorry, it seems that there are no available payment methods. Please contact us if you require assistance or wish to make alternate arrangements. Since your browser does not support JavaScript, or it is disabled, please ensure you click the Update Totals button before placing your order. You may be charged more than the amount stated above if you fail to do so. Update totals Your personal data will be used to process your order, support your experience throughout this website, and for other purposes described in our privacy policy. Place order
