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All submitted information is strictly confidential.

Providing your contact and insurance information helps us determine eligibility and scheduling.

If you are uncertain about providing your information electronically, please contact us at 989.954.4673 to be screened over the phone

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone Number

(###)

###

####

May we text you at this number?

YES

NO

Email

What insurance provider do you have?

Insurance ID/Member ID/Enrollee ID/Policy #

What issues/symptoms are you experiencing?

What are your currently available dates and times for appointments?

Are you interested in services based at our Mount Pleasant or Traverse City location or virtual services? (if you prefer face to face but are open to virtual please pick that one)