Please note: Payment for services, balances, copays, self-pay charges, and any non-covered services is the responsibility of the patient or responsible party. Insurance coverage is not a guarantee of payment, and remaining balances may still be due after claims are processed. Appointments should be canceled or rescheduled with as much notice as possible. Repeated missed appointments or late cancellations may affect future scheduling or be subject to the clinic's cancellation/no-show policy. Electronic communication through this form is for general contact only and is not for urgent medical concerns, sensitive medical-history details, insurance ID numbers, Social Security numbers, or payment card information. By submitting this form, you acknowledge that you understand these office communication, financial, insurance, appointment, and privacy notices.
