Name *

First Name

Last Name

Phone number for consultation call *

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I understand that Dr. Elliott requires payment at the time of service and does not bill insurance companies directly. I may, however, request a superbill to submit to my insurance provider for potential reimbursement. *

Acknowledged

I understand that the initial phone consultation is available to help assess whether Dr. Elliott and I may be a good fit, though a final determination will be made collaboratively following a comprehensive evaluation.

Acknowledged