Name *

First Name

Last Name

Phone *

(###)

###

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Address *

This helps us confirm that you live in North Carolina.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Notes on Insurance *

I understand that we cannot accept patients who have Medicare.

I have reviewed the FAQs webpage and understand that we currently only accept Aetna and Blue Cross Blue Shield as insurance providers, as well as out-of-pocket (private) pay. For private-pay patients who have out-of-network insurance, we are able to provide invoices (super-bills) for you to submit to your insurance provider as out-of-network claims, which may result in partial reimbursement for our services.