subject_line
Initials:
*
Initials:
*
Card Number:
*
Exp
*
Sec. Code
*
Zip
*
Initials:
*
Initials:
*
Initials:
*
Initials:
*
Initials:
*
Initials:
*
Initials:
*
I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE ABOVE POLICIES, AND AGREE TO
ADHERE TO THEM BY SIGNING BELOW.
Client's Name
*
Client's Signature:
*
clear
Date:
*
+
Doctor's Signature
clear
Date:
+