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I agree to terms, conditions, privacy policy and telehealth.
Request a
screening / appointment
We only charge if you are approved – guaranteed
Please fill out the information below and a member of our team will contact you to answer all your questions and walk you through the process.
I am:
New patient
Renewal Patient
First Name (on photo ID):
Last Name (on Photo ID):
Phone Number:
Email:
Preferred appointment Date and Time:
Date of Birth:
Do you have a qualifying condition:
Yes
No
Do you have medical records of the above condition :
Yes
No
I agree to
terms, conditions, privacy policy and telehealth
Must be at least 18.
Medical Records to Fax
#309 329-5159
Request a
screening / appointment
We only charge if you are approved – guaranteed
