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New Client Relief Request

Please fill out all sections completely. We will contact you with further information and necessary forms.

Who owns this practice? If corporate please list which one below.
What type of relief do you need?

Thanks for submitting!


Please note  - we can only begin working on your date requests once we receive all required paperwork.
If you have dates in the future, we encourage you to sign up and submit your request as early as possible to reserve your place in the queue. We can accept requests up to one year in advance.

We email schedules to all clients with pending requests at least twice a month. If you don't receive a schedule, please call us!


Lighthouse currently services the following areas:


Central and Southern Indiana

Western Pennsylvania

Northeast Kentucky

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