Patient Intake Form

  • Personal Details

  • Emergency Contact

  • Other Information

  • By signing above I understand that a 24 hour notice is required for scheduling or cancellation of appointments to avoid a charge. I understand and agree that all services rendered me are charged directly to me and that I am responsible for payment. In the event of default I promise to pay legal interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection.
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