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To register, please complete the bottom portion of this form and send it by mail, fax, email, or bring it by in person to: Resolutions Therapy Attention: Michael Hunter 982 N. Tyler Suite B Wichita, KS 67212 Phone: fax: (316) 721-8118 (316) 721-8139
Method of Payment: [ ] Check [ ] Cash [ ] Credit Card All payments must be made in advance unless prior authorization has been given. Name (as it appears on card): ________________________________________________ Card #: ________________________________________________________ Exp. Date _________________ Auth. Code _________________
(Three-digit code on back of card)