Patient Information

All fields with marked with an * are required

  • Date Format: MM slash DD slash YYYY

  • Credit Card Authorization

    To confirm your first appointment, you will need to submit a credit card below.

    Your card will be securely put on file. Your card will not be charged unless you miss or cancel a scheduled appointment with less than 48-hours notice.

    I will always offer to accept payment directly from you before charging your card.

    By submitting your credit card information below your are agreeing to abide by Dr. Bear Korngold’s late-cancellation/no-show policy (click here for more details).
  • American Express

  • This field is for validation purposes and should be left unchanged.