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Patient Intake Form

Please fill out the following form prior to your appointment.
Upon submission, you will be redirected to our appointment page,
where you can request an appointment. 

By filling out the form below, you acknowledge that you have read and understand our HIPAA/Privacy form and our Telehealth Services policy.

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You identify your gender as:
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Preferred Pronouns:
What is your race?
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You partner with:
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Thanks for submitting!

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