Who We Help
Please note: Submission of this form is not confirmation of a scheduled clinical consultation.
The information you provide reflects the desired date/time that your office would like to have a clinical consultation performed. We will make every attempt to schedule a clinical consultation on the date of and within the 2-hour window you have selected. If we are successfully able to schedule a clinical consultation in accordance with your request, we will send an email confirmation with the exact time during which our Medical Director/Therapist Reviewer will contact you. This will reflect the start time of a 15-30 min appointment. If we are unable to schedule your clinical consultation within the 2-hour window requested, one of our agents will contact you telephonically to offer additional times.
Please be sure to include a direct contact number or add comments in the Message field to describe any phone tree nuances we may need to be aware of to ensure successful contact with your office.
Required fields marked with "*".