GENERAL INFORMATION
I UNDERSTAND I AM FULLY RESPONSIBLE AND LIABLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE PLAN (IF APPLICABLE). I AGREE TO PAY A CANCELLATION FEE OF A MINIMUM CHARGE OF $25 IF I CANCEL AN APPOINTMENT WITH LESS THAN 24 HOURS' NOTICE.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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