Consent to pre-book V2

Consent to pre-book
I consent to pre-book this treatment/ treatments for blanks* and pre-authorized my credit card of Type a label* .

I understand my treatment is subject to the Doctor's approval and passing of my good faith exam.
If for any reason the doctor does not approve my treatment, the pre-authorization amount will be refunded.
First Name*
Last Name*
Email*
Patient email on file
Patient Signature*

Clear
Date*

MonthDayYear
Date
Provider Name*
Provider Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: