Download the application packet here.
Either print out the Consent Form or use a PDF program and fill it out in its entirety. You must fill in all information, including prescription insurance BIN, PCN, ID, and Group information. You can email the form to firstname.lastname@example.org or drop it off in-store. If information is missing, it will be denied.
Once we have your completed form, you will get a phone call to schedule your appointment.