New Patient Scheduling Form

Please fill our scheduling form and we will contact you within one business day with options.  You can also schedule by calling (888) 702-7974 x2.

ONLY FILL OUT THIS FORM ONE TIME. 

See our full financial policy and FAQ's before scheduling. *Details to know:

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

  • Refunded deposits require a $25 processing fee (no fee for rescheduled New Patient Appointments with 2 business days' notice).

  • PIM is out-of-network and cannot accept insurance. Patients with insurance can submit for reimbursement after each visit. Medicare or Medicaid (even if it is secondary) cannot submit for reimbursement.

  • Cancellation policy is 2 business days . A late cancellation fee applies for paid appointments cancelled with less than 2 days' notice.

  • We see patients ages 11 and up. Exception: Dr. Lotito sees patients 4 years-old and up and requires a Free 20 Minute Consultation.

  • Patients 18 and older must schedule their own appointments (a legal guardian may schedule only if the patient is unable to).

Please be sure to read the policies listed above. *
Name *
Name
As listed on health care coverage card
Mobile Phone *
Mobile Phone
Date of Birth *
Date of Birth
Guardian Name (If patient is under 18 only)
Guardian Name (If patient is under 18 only)
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.

If you schedule a Free 20 Minute Consultation, 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.