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Use this form to request an appointment with us. While we will do our best to accommodate your requested day and time, please note, your appointment is not fully booked until you get a confirmation from us!


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Please do not submit any Protected Health Information (PHI).


THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, TO CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND RESPONDING WITHIN 72 HOURS TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT.

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