For my safety I require verification. All of your information is kept confidential. Please fill out as much of the following information as possible. Anything with a purple asterisk is required information.

If you are not able to use Preferred411 or provider references for screening then I will require all of the following information for verification: name of your employer, your position, work email, cell number, current city and state of residence, a copy of your driver’s license (or passport for those visiting from outside the U.S.), and a comparison photo (photo of you holding your ID next to your face).

If you are using employment information for verification a $25 non-refundable deposit will be required, which will be applied to your appointment fee. The payment link will be sent to you after I’ve received all the required screening information.

Any explicit correspondences, inquiries regarding services or rates, or mention of “menu” acronyms or terms will be ignored and you will be put on my “Do Not See” list.