This form is for purchasing a consult.

Once you purchase a consult fee, our scheduler will contact you the same or next business day. Your contact information must be accurate in order to be contacted.

Once purchased, you may contact us:
Call or text (425) 428-4181
Email info@partingtonps.com

Patient Contact Information

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Where are you located? (city/country) *

Billing Information

Use different billing contact information (optional)

Billing First Name

Billing Last Name

Billing Phone

Billing Email

Country / Region

Street Address

Town / City (optional)

State / Province

Zip / Postal Code

Additional information

Payment options

Credit card

Pay with your credit card via Authorize.Net.

Card number *
Expiry (MM/YY) *
Card code *

Update TotalsUpdate totals

Your personal data will be used to process your order, support your experience throughout this website, and for other purposes described in our privacy policy.

Add a note to your order

I confirm that I have read and fully agree with these terms*

• This consult fee is applied towards the procedure but is otherwise non-refundable.

• My phone number and email are correct so I can be contacted.

• If I am in the USA or Canada, I will be called to schedule.

• If I am outside of the USA or Canada time zones, I may be emailed to schedule instead of a phone call.

• To schedule, I can call or text 425–428–4181 to reach the staff.

Order summary

Product	Subtotal
1 Consultation $200.00	$200.00
Subtotal	$200.00
Total	$200.00

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Patient Contact Information

Billing Information

Additional information

Payment options

Order summary

Order summary

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