HIPAA Secure Form

Secure Appointment Verification

To secure your appointment slot, we require a validated payment method on file.

There is no charge today ($0.00).

Card Information (No Charge Today)Your card is stored securely. You are NOT charged today.
Card Information
Appointment HoldQuantity-
RTS Appointment – Card on File
1
$0.00
Order Summary
Appointment HoldQuantityAmount
RTS Appointment – Card on File1$ 0.00
Order Total
$