Am I a Candidate?

If you are ready to take the first step to break the bond of alcohol addiction, please fill out the Alcohol Detoxification questionnaire below. Our alcohol detox physician specialist will personally review your answers and determine whether Rejuvenation™, our proprietary anesthesia-assisted alcohol detox method, is right for you. If it is, our detox program specialist will help you enroll in our program and setup your free, no-obligation consultation. If not, we’ll help you find someone who can.

Free Consultation with our Alcohol Detox Physician Specialist

Strictly Confidential
The privacy and confidentiality of any information you provide is legally protected, beginning with your first phone call, email, or otherwise. We are also exceptionally careful when handling complex family situations, and can work with you in any capacity to send information or speak in private.

Please complete this entire form in preparation for your FREE consultation.