Accepting Medicaid Soon

Self Pay or HSA patients, please complete the form below,

and you will be contacted soon to schedule your first intake appointment.

Name

First Name

Last Name

Phone (optional)

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Appointment Type

Message

If requesting a CO Medicaid appointment please enter your Medicaid Number below. As soon as medicaid reimbursement is active you will be contacted for an appointment.

Accepting Medicaid Soon

Patients who do not have commercial insurance or do not qualify for CO Medicaid, can be given sliding scale pricing for appointments.