Appointment Booking Agreement
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
I agree to pay a non-refundable new patient booking fee of $50.
This amount will be applied towards 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 cancellation fee in the event of no-show or appointment cancellation without 24 hours prior notice.
Signature
Submit
Clear Form
Should be Empty: