Fredericka Fairchild

VIRTUAL SECRETARY CONTACT FORM
Fredericka Fairchild MA, Healing Arts LLC

Please fill in the following information and submit. Once we receive your payment method you will be emailed to schedule a convenient appointment.
7-Business Days cancellation or re-scheduling notice is required.

After submitting the Virtual Secretary Contact form below, please know that payments must be received in order to schedule and confirm an appointment. You may call the office directly or eMail with a Visa, Master Card, or American Express number only, including expiration date, and CVC/CSC (Card Verification Code or Card Security Code) along with your billing address and zipcode.

Your Name:

eMail Address:

Mailing Address:

City State Zip Code Country:

Confirmed Billing Address if different from mailing address:
(necessary for credit card payments and Paypal.com)

Day Time Telephone Number Including Work:

Month, Day, Year of Birth:

Time of Birth: (leave blank if unknown)

Location of Birth: (Nearest large town, include State and Country)

Gender, Marital Status

Children:

Profession:

Who made this referral: (leave blank if non-applicable)

Question/Special Concerns:
(Include any medical condition, relationship, career or important issues)

Healing Arts are available in the Shelter Island or Palm Beach office or by Telephone, EST on
Mondays - Thursdays from 7:30 AM - 3:00 PM
Please indicate dates and times over the 3 weeks you will be available for a consult:

Where would you like your session:

Once you submit this form, please either telephone the office, or email with your payment method.

Fredericka Fairchild MA Healing Arts LLC