Robert Winer M.D.
Robert I. Winer, M.D.
To Schedule a Second Opinion Consultation
To See for Psychoanalysis
Payment Authorization Form
Second Opinions / Medical and Psychological Mysteries / Specialized Consultant and Psychotherapeutic Services
Robert Winer M.D.
to Schedule a SECOND OPINION CONSULTATION
NO INSURANCE ACCEPTED
Initial consultations $750 USD payable at the time of visit.
FEE for follow-up visits and special services PROPORTIONAL TO TIME SPENT
Prices may change without notice.
For Dr. Winer
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Name
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Address
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Patient's Name (enter "same" if info is above)
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Patient's Date of Birth
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Email
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Phone Number
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Problem
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1 neurological?
2. cognitive?
3 psychological?
4 All or some of the above.
Effects of the Problem
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1. primarily neurological
2 primarily cognitive
3 primarily cognitive with some psychological effects
4 primarily psychological
Is there (explain in section below)
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a history of brain or nervous system damage or injury?
developmental disorder
cognitive decline
neurological diagnosis?
psychological diagnosis?
none of the above
Tell me about your condition
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Question / What you need?
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