For testing: In order to assure validity of testing, the same tests cannot be administered
within a twelve month period of time. I hereby attest that my child has not been
administered or exposed to the same tests that will be administered by Dr. Cherwony
during the past twelve months. I further understand that no less than 72 hours advanced
notice must be provided in the event that appointment needs to be canceled. Failure to
provide such notification will result in an assessment fee of $250 and any rescheduled
appointments will require full payment in advance.