Please fill out this confidential form so that we may process your membership request in a timely manner. All information is handled in a highly secured manner in compliance with HIPAA regulations and is used for the sole purpose of establishing and tracking membership data. At no time will your personal information be sold, traded, or shared with any outside parties without your express written consent.
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Please note due to the personalized service we pride ourselves on, all initial consultation(s) will be billed as a scheduled visit.
Thank you for your time and interest.
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