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A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
In case of emergency, we should notify:
Please note, patient is responsible with providing us a copy of their insurance card(s).
Do you or have you ever had an adverse reaction or allergy to:
Please check those that apply:
I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.