Client Information

Your Full Name *

DL#

Spouse's Full Name *

DL#

Address

Street Address

City/Town

State/Province

ZIP/Postal Code

Email Address *

Home Phone Number

Cellular Number

Work Number

Emergency Contact

Emergency Phone Number

Emergency Contact

Emergency Phone Number

Current Employer

Employer’s Address

Street Address

City/Town

State/Province

ZIP/Postal Code

Unit

Rank

Commanding Officer

A deposit is required before any treatment is performed.
We accept cash, VISA, MASTERCARD, and DISCOVER. We accept checks only from established clients. There is a $50.00 charge for returned checks.
We must have a copy of a valid driver's license on file for each client.
We offer CareCredit to those who qualify.
New Clients: We are not able to take personal checks until you become an established client. We apologize for any inconvenience.
All fees are due at the time services are rendered.

By signing below, I understand and agree to the above terms and verify that all information that I have provided is correct and current.

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