Client/Patient Registration and Policies

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Please complete this form so that we may create/update your account. Section 1 is the primary owner's information. You will have the opportunity to add a co-owner if you'd like. Account holders must be at least 18 years old.

First Name *

Last Name *

Cell Phone *

Home Phone *

Date of Birth *

Account holders must be at least 18 years old.

YYYY

Billing Street Address *

Billing City, State, and ZIP Code *

Billing COUNTY of Residence *

Email Address *

Personal email addresses only. We cannot accept work email addresses.

Would you like to add a co-owner?

Yes

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