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704.489.2273

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Patient Data

Mailing Address

Current Complaints

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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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Family History

Habits

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Monday7:30 am4:30 pm
Tuesday9:30 am6:30 pm
Wednesday9:30 am6:30 pm
Thursday7:30 am4:30 pm
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SaturdayClosedClosed
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