Secure Email Contact

To reach your clinician directly, message them through our patient portal HERE

I'd like to reach...*

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*

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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