Client Setup Sheet

One World Trade Center
Suite 1600
Long Beach, CA 90831
Phone: (562) 436-7963
Fax: (562) 436-21780

CLIENT SET UP SHEET

NOTE: An Asterisk (*) Indicates REQUIRED Information.

DATE OF INITIAL APPOINTMENT:

*NAME:

*EMAIL ADDRESS:

STREET ADDRESS:

CITY/STATE/ZIP:

BILLING ADDRESS:

CITY/STATE/ZIP:

ATTN:

TELEPHONE: (W)

(H)

WORK FAX:

Call before faxing?

HOME FAX:

ISSUE OF CONCERN:

ANY KEY DATES:

REFERRED BY:
(person, yellow pages,
other, please specify)

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