Your appointment time has been reserved for you. In courtesy of your therapist and fellow patients, we kindly ask that you provide us with 24-hour notice of cancellation, or a cancellation fee of a full treatment fee will be charged.
I authorize the clinic and its associated RMTs to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contact numbers I have provided. In addition, I authorize the clinic and its associated RMTs to communicate with my referring MD as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.