Feel free to download the forms and bring them in with you for your first visit or arrive 15 minutes early to complete at your first appointment.

For Children

If you are making an appointment for a minor, please complete the following form in addition to the forms above.

Payment Policy

Payment is due at the time of service. Payment methods accepted are cash, check, major credit cards, debit cards, flexible spending accounts.

Insurance Policy

MERCI is an “out of network provider.” We will provide you with a receipt that will include date of service, diagnosis code, and amount paid so that you can submit it to your insurance provider for reimbursement. Because each policy has different co-pays and deductible limits, please check with your insurance company to confirm coverage.

Appointment Cancellation Policy

A professional time commitment is reserved and held exclusively for you. If you need to cancel or reschedule, please notify front office staff at 901-729-7825 at least 24 hours in advance. If the change is made with less than 24-hour notice or if you do not keep your scheduled appointment, you will be responsible for the full fee.