Consultation Request for Dr. Darcy Dane

How did you hear about our office? For our referral program, please enter the name of our patient who referred you next to other. *
Due to the constraints of working as a provider for an insurance company, Dr. Dane has elected not to participate in any insurance programs. There is no reimbursement available for treatments or services. Payment is expected at the time of service. *
Thank you for taking a few minutes to complete this form. In order to best serve you, our patient advocate, Teri Gray, will be contacting you shortly!
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