Dr. Arif Mirza MD

WELCOME TO

Virtual Private Psychiatry PLLC

(dba Germantown Private Psychiatry PLLC)

Accepting New Patients – Same Week Availability

Self Pay Pricing

First Visit $299

Follow up Visit $129

Family $109

We are out of network with all insurance plans

Updated: 11/01/2022

Virtual Appointment Request

Name of Person Making Request*(required)

Email*(required)

Phone*(required)

Relationship to Patient*(required)

Patient Name (First, Last)(required)

Patient Date of Birth (mm/dd/yyyy) & Age(required)

Requested Date* (mm/dd/yyyy) - Please provide 1st & 2nd pref.(required)

Reason for Visit(required)

Patient Gender(required)

Referred By (Doctor, Therapist, Google search)(required)

Accepted Insurance (If your plan is not listed, you will be booked as Self-Pay)(required)

Briefly list your concerns or symptoms: (ADHD Testing, Depression, Anxiety etc.)

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