It’s Time to Get The Help You Deserve. Contact us.Phone: 706-353-2550Email: Info@DrAshford.com1750 S. Lumpkin St. Athens, GA 30606 Name * First Name Last Name Email * Phone * (###) ### #### Which insurance provider do you have? * If none, simply write N/A. Date of Birth * MM DD YYYY Are you interested in the Ashford Center's weight loss program? * Yes! No. What can we help you with? * How did you hear about us? * Select all that apply. Youtube Ad Facebook / Instagram TikTok Google Search Radio Friend / Family Other If someone referred you, please write their full name below. Confidentiality Notice * I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. I Accept Thank you for submitting a scheduling form. To help us create an estimate for all services, please send an image of your Insurance Card to info@drashford.com