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Therapy Prepayment

Make a payment on your future therapy services.

$0.00

Patient Name

DOB (mm/dd/yyyy)

Business Day Delay

If payment made after hours, on the weekend or holiday, your payment may not be posted to your account until the next business day. Please show your emailed receipt at your upcoming appointment.

Refund Policy

I will not be refunded if services are rendered. However, I acknowledge I will be refunded if my provider does not agree with the plan of care and services are not rendered.

Payment Amount

Please Enter the Amount You Are Paying = $1.00

Qty:

Qty

Description

Therapy Prepayment

My Account

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Therapy Prepayment

Products from the same brand

My Account

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