Name *

First Name

Last Name

Phone *

(###)

###

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Are you a... *

New Patient

Previous Patient of Dr. Weiner's

Not contacting as a patient

(For patients) My offices are in South Miami, Hollywood, and Deerfield. Where do you prefer to visit (checka all that apply)

South Miami

Hollywood

Deerfield Beach

If you're a patient, do you prefer: *

In person

Telemed

Both in-person and telemed are fine

I'm not contacting as a patient

If you're scheduling a consult, is it for: *

Pain management

Ketamine-assisted therapy

Medical cannabis

Other medical

Not contacting for consult