Coupon Form

Coupon Request Form

Please fill out all fields marked with * and submit our Coupon Form. Look for an email from us containing a link to our new patient coupon.

  • New Patients Only - excluding Medicare.
  • Due to federal regulations, this offer does not apply to Medicare/Medicaid or Federal Insurance recipients.
  • Excludes auto accident and work injury cases.
  • Payment for coupon is non-refundable if appointment is canceled with less than 48-hours notice.