(This is only available for established patients who live in WV or PA)

The phone number we call you may be from a blocked phone number or from our office phone
Enter your notes/comments here
This is an optional field. Please sign here if you wish to have your credit card information securely stored.
After signing your name, you may also write STORE or DO NOT STORE to confirm your choices in the signature box above.
We are not responsible for damaged or undelivered mail by the USPS or patient's typographical errors. Please Initial to confirm.