Secure Contact Form

To reach your clinician directly, message them through our patient portal HERE
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Request Your First Visit

If you've already sent the "Request Your First Visit" form above, continue below for any follow-up questions.
Pay Your Bill Online
Please use the TMS Contact Form or click here to learn about TMS.
Please use the Esketamine Contact Form
Release Information from MTC

If you've already sent the "Release Information" form above, continue below for any follow-up questions.
Use the link below if you need us to complete a disability or FMLA form.
Disability & FMLA Request

If you've already sent the Disability form above, continue below for any follow-up questions.
Got questions about scheduling, refills, or administrative matters? Please don't contact your provider about those (use the admin department above).

Is it a complex issue you're writing about? We may be able to give initial guidance, but it’s best to schedule an office visit or phone consultation as well.
Name*
Date of Birth*
MM slash DD slash YYYY
Phone*
Secondary Phone
Email*
Message*
Pharmacy Name
Pharmacy Phone
Medication Names*
List meds you need refilled or authorized. Tell us if you are taking them differently than prescribed.
If you've been off your medications for more than 3 days, let us know when you last took them. It may not be safe to restart at your old dose.
We'll get back to you by the next weekday for treatment issues. For emergencies, call our 24 hour line: (336) 525-9090
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Reynolda & Polo Road
1615 Polo Road
Winston-Salem, NC 27106-3831

Off Country Club Road
104 Cambridge Plaza Drive (corner of Country Club and Jonestown)
Winston-Salem, NC 27104-3556

1901 Adams Farm Parkway
Greensboro, NC 27407-6338