Patient Intake

Use the form below to to submit your insurance information.

Please provide your insurance information for evaluation. Someone in our office will contact you to schedule your appointment. Do not use this form until you have spoken with someone on our staff.

If you need to speak with someone on our staff about treatment, please give us a call ((850) 979-5633) or use our contact form.

Intake Form

We will also need a photo of your driver license. You can send the image to our clinc phone: (850) 977-5670. You may also take a photo of the front and back of your insurance cards and send those as well.