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TO BOOK A LIPEDEMA FUNCTIONAL CAPACITY EVALUATION, PLEASE FILL OUT THE FOLLOWING FORM. FIELDS WITH A RED STAR ARE MANDATORY. A MEMBER OF OUR SCHEDULING TEAM WILL CONTACT YOU DURING BUSINESS HOURS WITHIN 48 HOURS OF RECEIVING THIS FORM. IF YOU DO NOT HEAR FROM A MEMBER OF OUR TEAM, PLEASE CALL 818-722-2142 EXT 403.

​PLEASE NOTE THERE IS A $600 FEE FOR THIS EVALUATION THAT IS NOT COVERED BY INSURANCE. WE CAN PROVIDE A SUPERBILL SO YOU CAN APPLY FOR REIMBURSEMENT BY YOUR INSURANCE COMPANY. THANK YOU