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Patient Data

Mailing Address

Current Complaints

Insurance Information

*If an auto accident, please provide:

Signatures

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Medical History

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Family History

Habits

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