Self-Pay Booking

Request an appointment and pay out of pocket. Our team will contact you within 24 hours to confirm your visit.

HIPAA Notice: This form collects protected health information (PHI) solely for scheduling your appointment. Your information is transmitted securely and handled in full compliance with HIPAA privacy regulations. We will never sell or share your data with unauthorized third parties.

Secure & Encrypted Submission

Step 1 of 4 — Patient Information

First Name *

Last Name *

Email Address *

Phone Number *

Step 2 of 4 — Select a Service

Service *

Step 3 of 4 — Choose Date & Time

Appointment Date * Available Wed–Sat, within the next 3 months

Step 4 of 4 — Review & Submit

Name —

Email —

Phone —

Service —

Date —

Time —

After submitting, a member of our team will contact you within 24 hours to confirm your appointment. No payment is required today.

I understand this is a request and my appointment is not confirmed until our office contacts me.