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646-926-1274
[email protected]
Queens, NY
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About Us
Bio
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Our Services
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HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Home
About Us
Bio
Testimonials
Payment Info
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Book for Tebra
Home
About Us
Bio
Testimonials
Payment Info
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Home
About Us
Bio
Testimonials
Payment Info
Our Services
Forms
HIPPA Release Form
Informed Consent for Treatment
Informed Consent for Telemedicine
Card of File Authorization Form
Practice Policies and Appointment Guideline
Patient Demographic Form
Contact Us
Book for Tebra
Book for Tebra
646-926-1274
[email protected]
[email protected]
[email protected]
Queens, NY
Eduard Kandov, PMHNP-BC
Kandov Psychiatric Services
646-926-1274
Card of File Authorization Form
Card Type
MasterCard
VISA
Discover
AMEX
Other
Cardholder Name
Card Number
CVV
Expiration Date (mm/yy)
MM slash DD slash YYYY
Cardholder ZIP Code
I,
Authorize (enter name below) to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.
Customer Signature
Date
MM slash DD slash YYYY