Click Here to Read the Patient Selection Guidelines

If you think you meet the selection guidelines, go on to the next step.

If you are not sure, call Dr. Peraglie at 407-922-3424 or email him at drperaglie@gmail.com.

 

 

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Click Here to Submit your Patient Application on line

Use the Patient Portal.

You cannot save the application so once you start filling it out, you need to finish or you'll lose it.

When you submit it, you will receive a form confirmation. Print it out.

You will need a copy of this to submit with your packet.