Texas Patient Information and Consent

Emergency Contact

Please separate each medication to one per line.
Your discounted rate has applied for coupon MJJL
Initial Evaluation: $200/session
Follow-Ups: $125/session
Self Pay Fee Schedule
Initial Evaluation: $300/session
Follow-Ups: $200/session

Who is your Primary Insurance Carrier?

Who is your Secondary Insurance Carrier?

NOTE: The following links contain very important information regarding your care, your rights and responsibilities as a patient. Please read these documents before signing.
Sign Here