Patient Initial Contact Form
Only a physician at ARCA will read this information. All your information will be kept in the strictest privacy.
However, please understand that due to FDA and AMA regulations, you are not a patient of ARCA until we have formally accepted your application. We hope that we will be able to meet with you soon and help you on the road to getting a new shot at life!
Note: You must fill in all the fields ABOVE the red line in order for the form to send. The questions BELOW the red line are optional; they help us in pre-evaluation.