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Patient Data

Mailing Address

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*If an auto accident, please provide:

Attorney Info

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Signatures

Name of the Insured _____________________________________________

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.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

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Family History

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Office Hours

DayOpenClosed
Monday8:00am7:00pm
Tuesday8:00am7:00pm
Wednesday8:00am7:00pm
Thursday8:00am7:00pm
Friday8:00am7:00pm
SaturdayClosedClosed
SundayClosedClosed
Day Open Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00am 8:00am 8:00am 8:00am 8:00am Closed Closed
7:00pm 7:00pm 7:00pm 7:00pm 7:00pm Closed Closed