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Patient Data

Mailing Address

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Nature of Injury

Insurance Information

*If an auto accident, please provide:

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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Office Hours

DayMorningAfternoon
Monday7:30am- 12pm2pm- 5pm
TuesdayClosed2pm - 7pm
Wednesday7:30am - 12pm2:00pm - 7pm
ThursdayClosedClosed
Friday7:30am - 2pm
Saturday7:30am - 12pmClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:30am- 12pm Closed 7:30am - 12pm Closed 7:30am - 2pm 7:30am - 12pm Closed
2pm- 5pm 2pm - 7pm 2:00pm - 7pm Closed Closed Closed


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