Contact Form Legal Name * First Name Last Name Chosen Name First Name Last Name Pronouns Date of Birth * MM DD YYYY Email * Phone Number * (###) ### #### Describe in a few sentences why you are reaching out now. * Preferred Method of Payment * Insurance Out-of-network benefits Private pay Requesting sliding scale fee Insurance Plan * Insurance information is used to see if Dr. Lara is an in-network provider for you and to provide a copay estimate. Insurance Member ID * List all of the specific weekdays and times you would be available for ongoing appointments. * Where are you located? * Dr. Lara DiCarlo is licensed to practice in both NY and FL. Do you have any questions? How did you hear about this practice? * Thank you! Dr. Lara will typically be in touch within 1 business day. Her practice is closed on the weekends. Check your email (including junk/spam) for her response.
