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Patient Data

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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.

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Date ____________________

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Medical History

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Family History

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Office Hours

DayMorningAfternoon
Monday9 am - 1 pm3 pm - 6:30 pm
Tuesday9 am - 1 pm3 pm - 6:30 pm
Wednesday9 am - 1 pm3 pm - 6:30 pm
ThursdayClosed3 pm - 6:30 pm
Friday9 am - 1 pmClosed
Saturday9 am - 1 pm1st & 3rd Saturday Each Month
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9 am - 1 pm 9 am - 1 pm 9 am - 1 pm Closed 9 am - 1 pm 9 am - 1 pm Closed
3 pm - 6:30 pm 3 pm - 6:30 pm 3 pm - 6:30 pm 3 pm - 6:30 pm Closed 1st & 3rd Saturday Each Month Closed

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