MIDTOWN NEW PATIENT DEPOSIT
This deposit will reserve your appointment time and will be applied towards your charges on the day of your appointment. If the appointment is not cancelled/rescheduled 24 hours in advance, the deposit will not be refunded.

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First Name on Account*
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I authorize Midtown Family Wellness to debit the account listed hereon $20.00, & 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 Midtown Family Wellness Terms as referenced in the [Terms of Use] link below.

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Midtown Family Wellness
1259 Monroe Dr. NE Atlanta, GA 30306
(404) 810-9099

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MIDTOWN NEW PATIENT DEPOSIT This deposit will reserve your appointment time and will be applied towards your charges on the day of your appointment. If the appointment is not cancelled/rescheduled 24 hours in advance, the deposit will not be refunded.

MIDTOWN NEW PATIENT DEPOSIT
This deposit will reserve your appointment time and will be applied towards your charges on the day of your appointment. If the appointment is not cancelled/rescheduled 24 hours in advance, the deposit will not be refunded.