Name *

First Name

Last Name

Phone number for consultation call: *

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I understand that Dr. Simone requires payment at the time of service and does not work directly with insurance companies. I can request a superbill to submit for reimbursement to my insurance company. *

I understand that a phone consultation is offered to help determine whether Dr. Simone and I will be a good fit, but a final determination of fit will be made by both parties after a complete evaluation. *