ATTENTION: New Patients, please put NA in the required Account Number field (below). Existing Patients, please put your Account Number in the required field (below).


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Billing Information
First Name:
Last Name:
Company Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone Number:
Email Address:

Additional Information
Account Number:
Terms & Conditions:
Patient Name:
Date of Birth :

Appointment Cancellation Policy: There is an Appointment Hold Fee of $50.00 to $100.00 depending on the type of appointment scheduled. This is used to hold the appointment and will be put toward the co-pay or deductible if you show up for the appointment. If you fail to show up --no-show-- for the appointment or do not call 24 hours in advance to cancel, the Appointment Hold Fee will be kept by the agency. A "no-show" is someone who misses an appointment without canceling it within a 24 hour working day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. If it is necessary to cancel your scheduled appointment, we require that you call one working day in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care. To cancel an appointment, please call our office at (316) 636-2888. Again, if an appointment is not cancelled at least 24 hours in advance, you will be charged the Appointment Hold Fee; this will not be covered by your insurance company (see Appointment Cancellation Policy Terms & Conditions). Appointment Cancellation Policy Terms & Conditions: These Terms and Conditions, as may be amended from time to time, apply to all our services directly or indirectly made available online, through any mobile device, by email, or by telephone. By accessing, browsing, and using our (mobile) website or any of our applications through whatever platform (hereafter collectively referred to as the "Platform") and/or by completing an appointment reservation, you acknowledge and agree to have read, understood, and agreed to the Terms and Conditions set out below. These pages, the content, and infrastructure of these pages and the online appointment reservation service (including the facilitation of payment service) provided by us on these pages and through the website are owned, operated, and provided by Affiliated Family Counselors and are provided for your personal, non-commercial (B2C) use only, subject to the Terms and Conditions set out below. By making an appointment reservation with Affiliated Family Counselors, you accept and agree to the relevant cancellation and no-show policy as outlined herein. All appointments require an Appointment Hold Fee or Deposit (hereafter called "Deposit."). All appointments have a 24-hour cancellation period. In order to receive a refund of your Deposit, all appointments must be cancelled 24 hours prior to your appointment. No-show or cancellations without 24-hour notice will be charged the Deposit. No exceptions. By clicking on the "I Accept" button YOU ACKNOWLEDGE AND AGREE TO HAVE READ AND ACCEPTED OUR CANCELLATION POLICY AND UNDERSTAND YOU MAY BE CHARGED FOR ANY MISSED APPOINTMENTS OR CANCELLATIONS WITHOUT 24-HOUR NOTICE.