Free Consultation Questionnaire

Please complete this form at least 24 hours before your appointment so our providers can prepare ahead. This will help you get the most out of your free consultation.

We ask that new patients read our financial policy and FAQ's before their first appointments. Don't have time? Here's what we want to make sure you know  before becoming a patient:

  • A $300 deposit is due at the time of scheduling a New Patient Appointment.

  • There is a $25 fee for all refunded deposits. There is not a fee for rescheduled New Patient Appointments as long as 2 business days' notice is provided.

  • We are out-of-network which means we do not accept any insurance plans. Patients with insurance only can submit for reimbursement for their visits. Patients with Medicare or Medicaid (even if it is secondary) cannot submit for reimbursement.

  • We have a 2 business day cancellation policy. There is a fee for appointments cancelled with less than 2 days' notice excluding the Free 20 Minute Cosultation.

Have questions? Contact us at info@philly-im.com or call 888.702.7974 x0.

Please be sure to read the 4 policies listed above. We want to make sure you're in the know! *
Name *
Name
As listed on health care coverage card
See below for the link to our membership page.
Would you like to participate in any of the following PIM Programs?
Check all that apply.

Please let us know if you no longer wish to keep your appointment so we can offer it to someone else in need of care. Our providers set aside time in their schedule for each consultation. If you need to cancel a paid appointment, please see our financial policy.

For details on membership, click here.