Ph: 806.239.3848 | Fx: 831.471.8162 rgordhamer@gmail.com

Patient Registration Form

 

    1. Complete Patient Registration
    2. Complete the Assessment and Interview Evaluation
    3. Pay $150 with a Debit or Credit Card

    PLEASE COMPLETE ALL SECTIONS IN ONE SITTING. UPON COMPLETION CLICK THE "SUBMIT" BUTTON..

    Although some patients may finish sooner, we recommend allowing at least 20-40 minutes to complete. Please follow the directions at the top of the page in each section.

    We respect your privacy and will never disclose your personal information without your written consent.

    Don’t accept any help in answering questions. The answers must be solely your own.

    If you have any questions please call us at (806) 239-3848.

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