STUDENT-IN-CLINIC SESSION

PAYMENT FORM

Session Price: $35.00

This form is only to be used if you have already received a Student-in-Clinic Session and just need to pay for that session. Thank you!

First Name

Last Name

Email

Phone Number

Session Facilitated By:

Date Session Received

Comments

Thank you for your payment!

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801-785-5259

office@ihaofutah.com

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139 South State Street, Suite #6, Lindon, Utah 84042

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