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Patient Registration Form

Please fill out the following form to help us understand your physical condition.

Marital Status
Primary Insurance

Insurance Carrier: Please complete the information below for the individual who owns the insurance policy.

HIPPA Privacy Authorization - I authorize the following person(s) listed below to have access to my Protected Health Information such as: appointments, diagnosis, billing information, testing results, or any other information that may fall under HIPPA

Thanks for submitting!

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