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Client Information Form

Driver's License #:

Co-Owner Name (first & last):

Co-Owner Phone Number:

Are you a new or existing client?*

New

Existing

Patient Name(s):

1.
2.
3.

Full payment is required at the time of service. I understand that the staff will provide me with a treatment plan for estimated charges upon my request. By acknowledging below, I understand that I am financially responsible for all treatment services provided and medication prescribed.

I understand that I am financially responsible for all treatment services provided and medication prescribed.