Simply Well Chiropractic

Deposit for Care at Simply Well Chiropractic

Order Details
Description	This deposit is required to hold your appointment time when utilizing online booking.
Total

Contact
First Name*
Last Name*
Email*
Verify Email*
Phone*

Billing Address
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I authorize Simply Well Chiropractic to debit the account listed hereon $50.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Simply Well Chiropractic Terms as referenced in the [Terms of Use] link below.

This Deposit is NON REFUNDABLE, and is required to hold your preferred appointment. At the time of your Initial Assesment the remaining balance of $100 is required to move forward with establishing care at Simply Well Chiorpractic. If for any reason you need reschedule your appointment please contact Simply Well Chiropractic via phone in order to not loose your deposit. DAY OF CANCELATIONS or NO SHOWS are excluded from any refund or applied credit to future appointments at Simply Well Chiropractic.

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Simply Well Chiropractic
1190 Pacific Coast Hwy, Ste A Seal Beach, CA 90740
(562) 588-3909

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