Wibeto Practice PLLC

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Instructions: 1) Please use a laptop/desktop to register (don't use a phone) 2) Our psychiatrists are ONLY in-network with BCBS PPO & Aetna PPO 2) Our therapists are NOT in-network (Billing can prepare a Superbill)

First Name:*

Last Name:*

DOB:*

Sex:*

E-mail:*

Mobile #:*

Home Phone #:

Address:*

Zip Code:*

Patient Availability:

Days:

Sun Mon Tue Wed Thu Fri Sat

Referral Source:*

Reason for Visit:

Facility:

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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