Request Appointment | Access Multi-Specialty Medical Clinic

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

Preferred Appointment Date

Type of Consultation

Initial Consultation

Comprehensive 90-minute evaluation for new patients

TMS Therapy Consultation

Evaluation for Transcranial Magnetic Stimulation treatment

Ketamine Treatment Consultation

Assessment for Esketamine (Spravato®) therapy

Follow-up Appointment

Ongoing care and medication management

Second Opinion

Expert consultation on current treatment plan

Urgent Consultation

Priority scheduling for acute mental health concerns

Clinical Information

Primary Concern

Insurance Provider

📄 Insurance Card: After submitting this form, please email a photo of your insurance card (front and back) to:

Email: insurance@accessmultispecialty.com
Fax: (650) 727-0551

This helps us verify your coverage before your appointment.

Current Psychiatric Medications

Previous Treatments

Additional Information

Privacy & Confidentiality

All information submitted is strictly confidential and protected under HIPAA regulations. We will only use this information to schedule your appointment and provide medical care. Your privacy and security are our top priorities.