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. Important details to know:

  • A $300 deposit is due at the time of scheduling a New Patient Appointment. (You will not be charged when you fill out this form. We will contact you for the deposit once you choose an appointment time.) The deposit goes toward the total cost of the appointment. Each provider has different pricing. You can view appointment pricing here. There is no deposit needed to schedule a Free Consultation.

  • 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.

  • The cancellation policy is 2 business days . A late cancellation fee applies for appointments cancelled with less than 2 days' notice. Exception: For Free 20 Minute Consultations that are cancelled or rescheduled with late notice, there is no fee, but the consultation can only be rescheduled one time under this circumstance.

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

  • PIM is a good fit for patients who are engaged in their care. If you are scheduling for a family member, the prospective patient should be internally motivated. He or she must also be willing and able to communicate via the electronic patient communication portal. Pediatric patients, those unable to use computers due to physical disability and other patients (by special exception) can substitute a single person to communicate via portal on their behalf. Patients must also be able to sit in our waiting areas without disrupting others.

  • *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)
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.