Appointment Booking Agreement
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
I agree to pay a non-refundable appointment booking fee of $50 (for in-office consultation) and $45 ( for telehealth consultation)
This amount will be applied toward enrollment in our weight loss service portal for unlimited access to weight loss tools/resources at the time of the first visit.
This amount will be used as a no-show or same day cancellation fee in the event of no-show or appointment cancellation without 24 hours prior notice.
We accept payment via Zelle and credit card.
Zelle Payment
Credit Card Payment
Pay Appointment Booking Fee In-office
https://buy.stripe.com/6oU3cvbtlcRP2V25G13wQ02
Pay Appointment Booking Fee Telehealth
https://buy.stripe.com/3cIdR954XeZXcvC8Sd3wQ03
Signature
*
Submit
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