1. Please provide all information requested and be sure to provide a digital signature at the bottom of the form after reading and understanding the acknowledgment.
2. This is not a contract with our office. It is simply a way for us to be certain that you have read and understood some basic information prior to speaking with us.
3. After you have completed this form, please email it to us at firstname.lastname@example.org, with your first and last name in the subject line of the email.
PLEASE BE SURE TO DO THIS PRIOR TO YOUR SCHEDULED APPOINTMENT WITH OUR OFFICE!