Please Update My Information to include:

Please use this form to send us any additional information necessary! Do not use this form for appointment requests. Thank You!

Adult/ Parent/ Legal Guardian Name

First Name

Last Name

Your Email

Your Phone #

(###)

###

####

Credit Card #

Expiration Date MM/YY

Security Code #

Billing Zip Code

Any Other Additional Information You Would Like To Update:

Credit Card Authorization

Providing credit card information authorizes payment for services. A 3.5% processing fee applies to all credit card transactions. Thank you.

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Payment Processing and Authorization

To ensure smooth and timely payment processing, we require a credit card on file. By providing your credit card information, you authorize us to charge your card for any insurance copays or outstanding balances. If you prefer to pay by cash or check, please indicate this in the 'Additional Information' section of your forms. You may bring cash or check to your appointment, but a card will still remain on file for your convenience. Thank you for your cooperation!

I Acknowledge