— Billing Information —

Please fill out the form below

    Please include an Email Address or Phone Number so that we may contact you.

    Patient Name (Required)

    Patient Email (Required)

    Phone Number

    Your Name if other than Patient (Required)

    Relationship to Patient

    Patient Date of Birth

    Regarding Dr. Szynal account, Physical therapy account, or both?

    Please allow 2 to 3 business days for us to reply.