Appalachian Wellness Ctr À la carte Interval History/Follow Up Form
Email address *
Date of Completion of Patient ID Form *
Please Review & Complete this & all other forms. The documents at the bottom of this form require your signature.They will need to be printed out and signed by you. There is a $150 fee for missed 1 hour appt's and $500 for missed 4 hour appt's, this includes calling within 24 hours of your appointment to cancel.
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First Name *
Middle Name
Last Name *
Date of Birth *
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Preferred Name *
Cell Phone Number *
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