Confidential Patient Intake Form
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Name
Sex
Marital Status

Payment is expected at the time of visit. You will be expected to bring payment information or the form of payment required upon your visit. By submitting this form, you agree to the following.

PATIENT AGREEMENT: I understand and agree that health and accident insurance policies are an arrangement between my insurance carrier and myself. Furthermore, I understand that I am personally responsible for payment, both for services when rendered and for missed appointments if I fail to give twenty-four hour advance notice of cancellation.

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