New Patient Scheduling Form

Please fill our scheduling form and we will contact you within one business day with appointment options.  You can also schedule by calling (888) 702-7974 x2. Patients ages 18 and over must schedule their own appointments unless they are unable in which case their legal guardian may schedule. We see patients ages 11 and up.

If you have questions before scheduling, please request more information here.

Please read our financial policy and FAQ's before scheduling. Don't have time? Here's what we want to make sure you know before scheduling:

  • 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.

ONLY FILL OUT THIS FORM ONE TIME.  After that, simply contact us on the P2P portal, email info@philly-im.com to schedule, or call (888) 702-7974 x2.

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
Date of Birth *
Date of Birth
Mobile Phone *
Mobile Phone
The Free Consultation can be done by phone or in-office and is optional. The consultations will allow time to ask treatment questions and talk about your health goals with a provider to help decide if you are ready to become a patient and find the best provider for you. Because you are not a patient at this time, our providers do not review medical records, give medical advice, or start treatment at the free consultation. A New Patient Appointment can be done in-office only. This is when you begin your personalized treatment plan. We require a $300 deposit at the time of scheduling a New Patient Appointment.
If you are scheduling a Free 20 Minute Consult, please confirm if you would like us to call you or if you would like to come into the office for your consult *
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.