Patient Evaluation & Intake

Interested in pursuing treatment with one of APN’s affiliate providers?

Please complete the form below to pay the consultation fee required to begin the patient evaluation process. The consultation fee includes a review of your medical records to determine the best treatment option for you, based on your medical history.

If you require further assistance with a payment originating from outside of the U.S., call 901-235-2011 or email info@americanphysiciansnetwork.org.

Choose Consultation Option *

Standard - $ 125.00

Expedited - $ 475.00

Total Amount

Your Information

First Name *

Last Name *

Email Address

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

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Postal Code *

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