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LIFE MANAGEMENT FOR ADULTS, PLLC

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FOLLOW UP APPOINTMENT REQUEST

DONNA HEDBERG, PMHNP
PORTSMOUTH, NH - (In Office and Telehealth)

First Name

Last Name

Date of Birth

Email

Phone

SCHEDULE FOR SATURDAY / TELEHEALTH ONLY * Required

Soonest Available

Regular Follow Up

TELEHEATH METHOD: *

Visual Session

Phone Session

WHAT TIME OF DAY? * Required

10:00 AM

10:30 AM

11:00 AM

11:30 AM

First Available

CHOOSE LOCATION: *

In Office

Telehealth *

CHOOSE TELEHEATH METHOD:

Visual Session

Phone Session

*I will verify my Telehealth coverage with my insurance prior to my appointment.

Has your insurance changed since your last appointment? *

Yes

No

Upload pictures of the FRONT and BACK of your new Insurance Card

Upload Files

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Policy Reminder - Late Arrivals and No Shows

If you arrive more than 15 minutes late for your appointment you will not be seen. Your appointment will have to be rescheduled and you will be charged a $150.00 No Show Fee.

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