Please print and complete the form by clicking above and return or fax it to us
Due to increased demand for services, there is a $50 deposit required to schedule
an initial consultation with our providers. This payment may be made over the phone
using Visa, MasterCard, or Discover Card. In the event this appointment is not kept,
the deposit is non-refundable. If the appointment is kept the deposit will be used
as a credit applied to fees for services.