Waiting List Application

Appointment requests are taken by order of medical priority.

First name*

Last name*

Email*

Phone*

Please describe your current situation, relevant to requesting an appointment.*

On a scale of 1-10, what level of pain are you currently in?*

Contact Me

172 E Merritt Street, Suite A

Prescott, AZ 86301

Tel: 928-925-0434

First name

Last name

Email

Phone

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