Appointment Schedule Template

Schedule Your Consultation
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Would You Prefer an In-Person Initial Consultation or Telehealth?*

In PersonTelehealth

Appointment Request (In Office)*
Appointment Request (Telehealth)*

Appointment Deposit*

Appointment DepositNotice: To secure your appointment, a $25 deposit is required at the time of booking. This deposit will be applied toward your first treatment. Please note: Deposits are non-refundable if you fail to attend your appointment. To receive a refund, cancellations must be made at least 24 hours before your scheduled time. Thank you for your understanding and cooperation.

$25.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Opt-in to Receive Text Messages*

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Body Balance Medical. Message frequency varies. Message & data rates may apply. Text HELP to (702) 843-0590 for assistance. You can reply STOP to unsubscribe at any time.
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Schedule Your Consultation