1Your Info
2Reasons for Care
3Additional Concerns
4How We Can Help
5Insurance
6Choose an Appointment
7Secure Your Appointment
8Confirmation

Let’s get some basic info

Please make sure what you enter matches what your insurer has on file. This helps us verify your coverage quickly and accurately.

Name
Date of Birth
You must be 18 or older to book an appointment.
Email
Sex on file with insurer
We ask because insurance eligibility checks require the sex listed on your policy.

Primary address

Address

Referral source

Why are you seeking care?

These are the types of care we specialize in. Choose all that apply.

Reasons for care

Are you struggling with any of the following?

Choose all that apply. This helps us route you to the right provider.

Additional concerns
⚠️ If you’re in crisis, please call or text 988 (Suicide & Crisis Lifeline) or call our office at [OFFICE_PHONE]. You can still continue booking below.

Anything else you’d like us to know?

Optional — a short description (1–3 sentences) helps us match you with the right provider. Please avoid sharing sensitive health details you’re not comfortable writing down.

Insurance information

We’ll verify your benefits before your appointment. If you’d rather pay out of pocket, choose Self-pay below.

Payment type
Policyholder date of birth
Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.
Photos from your phone are fine. Make sure the text is readable.
Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 10 MB.
Photos from your phone are fine. Make sure the text is readable.

Self-pay rates will be shared by our team after you book. You’ll receive a rate confirmation before your appointment.

Self-pay acknowledgment

Choose your provider and time

[Appointment Picker — to be built]
This step will call the AdvancedMD API via WordPress middleware to show filtered providers and available times. Patient’s Step 2/3/5 answers feed the filter.

Hold your appointment

We don’t charge anything today. We save your card to hold your appointment and to cover our late cancel / no-show fee if needed.

Cancellation policy
Appointments cancelled less than 24 hours before the scheduled time, or missed entirely, will be charged a $[FEE_AMOUNT] fee to the card on file. You can cancel or reschedule free of charge up to 24 hours before your appointment by calling the office or using the link in your confirmation email.
Policy acknowledgment
[Card on file — to be built]
A tokenization iframe from the chosen payment processor will live here. Do not capture raw card numbers in Gravity Forms.