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Last Name *
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Phone *
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Appointment Date
Appointment Time
Reason for Appointment *
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*Cancellation Policy:* The patient has 24 hours prior to the appointment to cancel or change the appointment. In the event that patient does miss the appointment, we reserve the right to charge the patient for the consultation.The 24 hour cancellation policy is a courtesy to the doctors at The Selem Center and their time.
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