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Patient Intake

Is the patient under 18 years old
No, the patient is 18 or older
Yes, the patient is under 18

Please fill this out before your visit. It takes about 10 minutes and saves you about 15 minutes in our waiting room.

Date of birth
Month
Day
Year
Sex at birth
Female
Male
Height, feet
Height, inches
How did you hear about us
A community event or screening
Drove by the office
Facebook or Instagram
Google
Insurance directory
Nextdoor
Referred by a doctor or provider
Referred by a patient
Yelp
Other
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CALL NEW PATIENT EXISTING PATIENT