Step 4: Review & Confirm

Please review your appointment details and confirm your booking

📅

Appointment Details

Doctor:

Date:

Time:

Type:

Duration:

Visit:

👤

Patient Information

Contact Information

Reason

Allergies

Insurance Information

ℹ️ Insurance Coverage: We accept most major insurance plans. Please bring your insurance card to your appointment. If you don't have insurance, we offer competitive self-pay rates.

Do you have health insurance?

Yes, I have health insurance

No, I will pay out of pocket

Insurance Provider

Insurance Provider Name

Member ID

💳 Out-of-Pocket Payment

30-minute consultation: $175

Payment will be automatically charged 3 days before your appointment using the credit card information below.

Credit Card Information

Name on Card *

Payment Responsibility Agreement

I understand and agree that I am responsible for payment of this visit regardless of my insurance processing or coverage. *

🔐 To complete your booking, we'll create a secure patient account for you. This allows you to manage appointments, access your health information, and communicate with your care team.