Please note ,if you are a returning patient you don't need to fill this form. Please call the front desk and book appointment at your convenience. Thank you.
Please note this will be the primary number to contact in case of an emergency/cancellations by the clinic. The clinic will make two attempts to reach you. You may provide an alternate number to reach you. Please let the front desk know if you prefer a different way to communicate for unexpected clinic closures. Thank you for understanding.
Please print your name
Client authorization for Disclosure of Information: