Book your appointment

phone 847.859.9205

fax 312.586.7746

info@connectedneuroscience.com

4711 Golf Road, Suite 1200
Skokie, IL 60076

Thank you for your interest in scheduling a consult. Please complete this form. After our office receives this form, we will send you preappointment paperwork via email through our electronic health record, Osmind. Please be on the lookout for an email from Osmind and complete these forms as soon as possible. Once these are completed we will contact you to discuss an appointment. If you have any questions, please let us know.

Name

First Name

Last Name

Phone

(###)

###

####

Age

How did you hear about us?

Briefly, why are you request a consultation?

Acknowledgment

By requesting this consultation, I acknowledge that Connected Neuroscience is out of network with commercial insurance and does not accept Medicare or Medicaid for services, but a superbill can be provided to me, if requested, for out of network benefits through commercial insurance. [check box]

Yes, I understand