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New Patient Intake Form

Do you have a history of any of the following:

Note: “Thank you for you submission. We have received your application and you will receive a response within 5 business days to the email address on file. IF you do not hear back after 5 days, please feel free to contact the office.

The information submitted on this form is for screening purposes only and may not be kept on file. If our team decides we are not the best fit for your case and your application is denied, notification will be sent to the email address on this form.”