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I acknowledge and agree to the terms and conditions outlined on the previous page of this online scheduler. I understand that falsification of/or failure to provide accurate information may result in cancellation of my appointment.
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Card on File Required
A hold of will be placed on your card. You will only be charged if you miss your appointment.
Card on file
A hold will be placed on this card. You will only be charged if you miss your appointment.
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Notice
Private Pay
By checking this box, you are choosing to be a private pay patient.
Notice
Private Pay
By checking this box, you are choosing to be a private pay patient.