Name of Child *

First

Last

Name of Parent or Guardian *

First

Last

Phone Number *

Email *

What Service(s) Are you Interested In *

Do You Have A Referral For Service(s)? *

Yes: I have one
Yes: the referring provider has faxed it to Milestone
No: I will reach out to the referring provider

If you have a referral for service please fax to 619.578.2231, email to scheduling@milestoneclinic.com, or drop off at our clinic. If you do not have a referral for services, please contact your referring provider to have them fax the referral to Milestone.

What Insurance or Payment Method Will You Be Using To Cover Services? *

Our in-network insurances are always changing so please call our office to find out if we accept your insurance.

Referring Provider Who Will Be Sending The Referral *

First

Last

Referring Provider Office Name *

Referring Provider Phone Number *

Referring Provider Fax Number *