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Signatures

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I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

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Date ____________________

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Office Hours

Day Morning Afternoon
Monday 9:00am - 12:00pm 3:00pm - 6:00pm
Tuesday 9:00am - 12:00pm Closed
Wednesday 9:00am - 12:00pm 3:00pm - 6:00pm
Thursday 9:00am - 12:00pm 2:00pm - 5:00pm
Friday By Appt* By Appt*
Saturday By Appt* By Appt*
Sunday Closed Closed

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