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Appointment
Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
(Required)
Email
(Required)
Insurance Company Name
(Required)
Insurance Number
(Required)
Insured’s Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
MD’s Name
(Required)
MD’s Phone Number
(Required)
Therapists Name
(Required)
Therapists Phone
(Required)
Consent
(Required)
I give Daryl Ann Smith RD LC CEDS permission to consult with my MD and therapist for the purposes of team treatment.
Patient Signature
(Required)
Consent
(Required)
Charge for Late Cancellations less than 24 hours or no-show
(Required)
Credit card will be required to keep on file for late cancellations before an appointment is scheduled.
I authorize Daryl Ann Smith RD LD CEDS to keep my signature on file and to charge my credit card account as indicated below.
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