New Patient Sign-up Form

Use this form to register a patient for cognitive impairment therapy with one of our partner clinics. You will need your clinic's primary phone number to register.





You have left off some important details that are not technically required, but you are encouraged to provide as much of this information as you have available.

  • Contact information (phone number or e-mail address at least)
  • Biological sex (assigned at birth)
  • Education level
  • Patient vitals (blood pressure, height and weight)

* denotes a required field.

E-mail or call 984-232-6699, option #2 for assistance.

Return to the sign-in page