Appointment

New PatientExisting Patient

Patient Full Name: *

Date of Birth: *

Email Address: *

Phone Number: *

Home Address: *

Types of Appointments: *

Gender: *

Patient Full Name: *

Date of Birth: *

Email Address: *

Phone Number: *

Types of Appointments: *

We will be requiring a deposit of $20 to book an appointment. Once patient will show up on the appointment day at the clinic, we will refund your account the amount of $20. We are requesting if you could pay a donation of just $1 to cover a service fee for credit card transaction.

I understand and acknowledge that i will be requiring to make a deposit of $20 to book my appointment. without making a payment my appointment is not guaranteed

As Salam Clinic