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Confirmation Page

Please fill out the form below to confirm you appointment

Name *

First

Last

Phone *

Email

Email

Confirm Email

Check which method you would like to use for the virtual Visit *

• Phone call
• Video call

Purpose of the Visit *Weight LossOffice(Sick) VisitVirtual (video) Visit

Confirm Date *

Working Days: Monday - Saturday

Confirm Time

• 9 AM - 11 AM
• 11 AM - 1 PM
• 1 PM - 4 PM
• 4 PM - 5:45 PM
• 4 PM - 6:45 PM (Thur & Fri)
• After hours

Checkbox Items *

• Follow Up Visit
• Sick Visit
• Weight Loss

Additional Services *

Total

$ 0.00

Stripe Credit Card *

Card

Name on Card

Name

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Address

Email

info@centraclinic.com

Call Us

832 328-0044 or 281 861-0600

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Centra Clinic , Inc