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Terms and Conditions
Patient Information – please make sure all of these fields are required
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Terms and Conditions

Terms and Conditions
By booking an appointment, you agree to our terms and conditions, including our cancellation and no-show policy. If using insurance, you are responsible for any copays, deductibles, or balances not covered by your plan. A card on file is required at the time of your appointment for billing purposes. By proceeding, you also consent to be contacted by our practice via text, email, or mail regarding your care. Please contact us with any questions before booking.

Patient Information

Patient Type

First Name

Last Name

DOB

Sex

Address

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Insurance

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ID Card (Driver’s Licence or Other)

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Primary Insurance Card

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Location

Date Time

Reason for Visit

06/19/2025, 07/04/2025, 08/02/2025, 09/01/2025

08/18/2025, 08/19/2025, 08/20/2025 ,08/21/2025, 08/22/2025, 08/23/2025, 08/24/2025, 08/25/2025, 08/26/2025, 08/27/2025, 08/28/2025, 09/12/2025, 09/15/2025, 09/23/2025, 09/24/2025, 10/01/2025, 10/02/2025, 10/03/2025, 10/06/2025, 10/07/2025, 10/08/2025, 10/09/2025, 10/10/2025, 10/11/2025

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