AutoPsych Enrollment and Scheduling

New Patient Initial Evaluation Scheduling and Enrollment

Welcome! Let's get started.
Online Initial Evaluation(30-50 minutes). Please pick a time that works best for you.*

Monday 1-6pTuesday 1-6pWednesday 12-5pThursday 5-10p
Please Enter Your Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Your Email Address*
example@example.com
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*
Please enter a valid phone number.
Patient Signature*

Clear

Please submit payment to confirm your appointment:*

New Patient EnrollmentEnrollment includes: Comprehensive initial evaluation, unlimited visits, unlimited prescriptions, automatic monthly prescription refills, and 24/7 access to care with our amazing provider team. Cancel anytime.

$499.99 for the first month then,$99.99 for each month

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

New Patient Initial Evaluation Scheduling and Enrollment