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New Patient Form

Please fill out the fields bellow

Personal Information

 

Medical Information

Check here if you are the holder

 

Medical Record Release Form

I,                                                                                  hereby authorize the release of information as indicated: 

My Healthcare Information I authorize disclosure of healthcare information related to my medical history, diagnosis, treatment, or prognosis to all inquiries or only to the following people or entities: 

I choose                                            on the ABN form. 

By signing this, I acknowledge and understand the Notice of Privacy Practice, Lifetime of Benefits, ABN, and Medical Record Release. 

Signature:                                                                                                 Date: 

 

_______I have read and agree to the Summary of Notice and Privacy Practices.

CLICK HERE FOR ABN OPTIONS

Your Information Has Been Submitted.

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