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Name(Required)
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Address(Required)

Employer Address
Primary Care Physician Address
Ethnicity:
Race:
The Notice of Privacy Practices is posted in our office for your review. A copy may be provided for you upon request. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan, and direct my treatment and follow-up among the health care providers who may be directly and indirectly involved in providing my treatment, obtain payment from third party payers and conduct normal health care operations such as quality assessments and accreditation. I certify that the above information is correct and I request services.
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