JFIFC    $ &%# #"(-90(*6+"#2D26;=@@@&0FKE>J9?@=C  =)#)==================================================y" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?QVdnvzj^G,cr\::ka |QgȖK`|"QKu8'ӿe$ﱴRkroPV{A 3nqC\an&HNv8Qi]o.l׶GzNJݡ0 ܢT CY)NV rKixaZǹ4,'T90'$zkthCwm3UyeiiO\[,vA"wIc<ǥ4<+z4·VYQ!wJ4 :AZK>ybϕ͎gM-Q9S0 u >U=1QxY4), ȧXӻLr?AVcH·576M{OvoJSxQY~*mZmCSYmP]G v>.1@# yl8@OMhK{`@'ӳqwi= to/5a]峃|A4bOvDnSW q<Fۆ߃;ӥt]k !T7\汫]SQq~9C( .!U֤lm4c&Kky$Y}SlVX?އ8=Me:e?NBz4jǙ\iM~}^/W35ŵ";nG yJ{qj2K`PMOn"hVFf=7$㟭K{$1},\w̮.Eٶkfyyp1*0}1_E~Sձӊ/|QrYDfuؙۜ9qk/o{H-EbfrѫFCH& E&ևGdr }Mws:EHL 捾Sчn+4չjc EWi`bs9x#ҵ<*skI廐;[6/D"#rqӞI5}E!LKPxyr [tKO@TZ\Ʀyq"ƛ#^r =N9aܻĹcq^fn-RH@PDK\ ]GAs3oya;w7ʧUkz*G JoՒ2:~1]|YGkwwǓ>qߓڞ Mƥڋyd?695̲TԀQ*-V=G?*:U۩AӮ;{.qCvVt9S<ݚZ xnS]c)t%js7ma$vJ~h  +/P@<+"@PKw1!wgC>e5~c'njö:v%IdWVܤnQPM|HVt~uݮYUNm xEaBǡ(8$I-),|Aj Zi]z)SPٷxHuI.KtP/\U3}mcq-4q 0;]CI)tvC% qҕjg,䗗!0H I<(?cF0]FUR;?!'/LUOcRE7+-ksFuwm>[7̣q8^k& x9\MeA%\p!G?(ֻOz˦Z8gd.vw95CAbeÞ{ҵ>JP?}qvtjvȖ,J\)PTrj8í6w!lcsқ0 B08VEd;c$k7'k WK13ٛx#ĠICOp1p8]֥m2khaiՏ`y^Oy#NX1=kX%mV199Sd>)r[5mCzy]|=?_,ު(]2zs~,r-PH#؎]+Y:L6V+%'sߠ҉oCuK^;h^-X'~ЍÿNqznY"Fy"<}j;^_e[K(aؐ@5N)FM^4tP^@5-r-FO(\c~5\pTf+ZcUu{62m9ݽKJd8 kT֚Xn$#$b+ċ&j۰1g&fc2ķ/nJxOThlv Xunh+;ɜ' ZyaEhEsOii$  Ҵ-Fo9;2)jP(^*[z#^=d`BO8/ `e^{s/.Q=Ia,k [JKsJ4Y ེXHoGm`ia< p% tPJ*}89[<`'nMGQgҫ}km>B:qܰ5SWװ\F1z:T]^2GT$QOK|Q$~ wI c=+F|<¶i;q5 o;j){RqG :ѵ:f_1Y@O`ʗجWvgS>:b)<bײ NU96{,(UsL!;duUBG)7g ux7M&3-l8T/|Ap&@铞MAoXԡ$yQӽg(ʢ5Fί$ykn8jޝ޵;, Jk+6e#'?u$Um"YO]Qi6!r\rI?5ܰ&-6AtS# O Tcfvn߄OSR'?rw vAJbV{PUVҥpZ>$še!di%c[`wi0 E= Ǒ{u#iZ}MC /<~[͂z)TgԎ(99UӗRh,a P~خH c-K[9_NxnjIh$ѪS9P(M>NME[$=E"is6q ;fg.u$ʢn'ZLa"ޠݙE#icՁ)WiӤJIێzn?Ej4Q#F+RvG?\)>=yң@FTd#[fZ>̴Ô4qJ((9L?b[f}h lE lI-fZ\c ͞VEÔu:jҚOiz8DwMVLU ?&ivۅnCz)ad"W,9ⴭ/:٤G0+>mu:m7fCK |͒>GnBiwvnåMuq*"򎘨SIhɽYо1S3ϥ^K@3Ehb}^R y޶/. 6Iy&JZ=,7ovT?xy[bڴ7p1? ZDE0Ik|EMK-%*3oIŻjJ6[1[}]XwJ5;Y^/ˀ x|u2IaVQ֯4_i6g(&W?}ZT ]@4x˧DH>m#ȔܛsVrWj{k {(&ḦTџ8q}ky52c5SŞ}T3=/ݑQ31'bj_ya7Jþӵ(rQZ?Vjy}p]vCZ-Hc^IE[Oio rGNqE+D zS8B}~>QҲhܻ 6z0zRŤ[I$ϵau$J/fdrU۸u'ک(3nw2ҿc`bc=;M9|-],6l!b|{Js[_Ƭ`A!k {FfӣXA' +Q,^cc$?#-\/6!px{ҌlD">?ToiewF2}N£is154z"T'ܱoci"{Tw~P9?ZMơ*}5+OԜ>xH<Mo!wqQOpv!OEz~j=bBBn_+ֳNTssD֭oeg~taXIa%mK|}8AE=86D"4yfǘF"a_U|Oo,;(Ey|Y=z-WJ1B*o⦸i/itK"V$[-zx5y%V*UW$zVsH4IVf -eQP2ݤ%գ(]vI`359ܸޢ7G' гZ]IDY)Cv"u88.F: ݎ%IG-LBsְt{Sl2@#/<}FC6.g*kKPֆ5MBi_,BhX!_Ưb`)$7"EkĈS$1j3P?-2n:@tT-8V1~niƘSbEwJ3oysGp>x?0ްnY<~Ό8ݩs~.|iR,\lVPG8Y *LX}Njb BNkǕ}3]/ŏm 2NLT\_4OwWvΌmpO c5݃F.22\P2N,{WXy6Bn$Onk_%p{]qi L(l#x/W!+Dcw- FBZ2y+S ^,aWmku'7y3%d "J){#IگD.\Ytˁ$oЊڞ0U?JG>q̄Gr{fӮ3.q/8K2zj(F*;%ec5f<WSe8eOZ(ⱴsQZl-R$.qޤF&R3OA$} ~^(RiY~4(/?#jfN=>YB!,x[a[M6@b5𕹻VPJRkY,`A)7jƭΜ=&uEs*hT&Ȁf=OM'6q穯#5] QٵJ( 캕&צ9R~^}ޕښBNkc49k -thmoOk{bKB? J,qܛ~nuN{c%Dzw"ᦡۘRQ$w*uˤ'Fk]x4լ.*DkM/@X SHMhllB\*^ߕNU;-~U=ڊr+ &(fBI[?*WQA!X4 23+5 K+BѴMqĪUKd֋Xm ҁ\Z *_V 5d19V)$p#Ҁ5-tb: V8(Ebb[ ALwg}Xַ/O qj1 \6CUp3wIV)K ٍrkR >ŝ뺰 iknR= rA-Vk{d-1ֵ5|XX[yK–NH+cdSN1ڕ!'`A 6ڜ{KTpTX=0g[,8[ŒcC#!4YIH``(QwAU.4"KP9?6o&DzEgosxL͑DGS:vY [hS$~byy5r DMrBa xz|ѠΠN7h`|km¤w~ҍRdpFۭ+&s cjZ-ʲwWZ[\LV~?Zs. = >^sWB qE>R{ 'ğ *'y0d~)󸌀xW=i}MUѣ<+Pڎlp_*@u5AA==֒j:f[I$? /3i-ۊ`e($
Clinic Information
Preferred Clinic Dates
(Make Two Choices)
First Choice (Date):

Second Choice (Date):
Second Choice Day(s) of the Week:
Nearest Airport Airport Name: Miles to Clinic: