Name * First Name Last Name Phone * (###) ### #### I am able to receive text messages at this number I am able to receive voicemails at this number Email * Preferred Method of Contact Text Phone Call Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY Emergency Contact * First Name Last Name Relationship * Spouse/Significant Other Parent Family Friend Other Emergency Contact Phone Number * (###) ### #### Preferred Pharmacy Name Preferred Pharmacy Phone Number Please include the number to the pharmacy you prefer to pick up your medications at. (###) ### #### Policy * I understand that my Credit Card Information will be collected prior to my first appointment to cover the deposit, as well as subsequent expenses that remain unresolved after extended periods of time. I understand that there is a 48 hour cancellation period, and a cancellation fee of $200. I understand that if I don't show up to an appointment or cancel prior to 4 hours of the appointment, the entire fee for the appointment will be due. ChackoMD may waive the fees based on the nature of situation. Credit Card Number * Please enter your credit card info here. This is required even if you would like to use another form of payment. This is only a back up in case a bill remains unpaid for over two weeks and no arrangements have been made to settle it otherwise. Epiration Date * MM DD YYYY CVV * Preferred Payment * Venmo (@Andrew-Chacko)* Zelle (650.387.9518)* Ca$h App ($ChackoMD) Cash/Check Credit Card Username for Payment App Selected Above Thank you!