Please note that this form is intended for the uninsured adult patient with established seizure disorder or suspected to have seizure disorder and is willing to pay for his or her seizure disorder neurological care by an affordable payment plan. All patient must have a primary care provider in order to be seen at the clinic regardless of insurance status

I was diagnosed with or suspect i have a seizure disorderI am currently uninsured ( not covered by private health insurance. )I have a primary care provider

By completing this form and requesting an appointment I acknowledge that I have read and agree to the Health Service Agreement for the Treatment of Seizure Disorders for Cash Paying Uninsured Patients.