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Health History Form

The information requested below will assist us in treating you safely. Feel free to ask any questions about the information being collected. Please note that all information provided will be kept confidential unless allowed or requested by law. Your written permission will be required to release any information. Please inform us of any changes to your health status/medications, etc.

Personal Info
Contact Info
Emergency Contact
Doctor
Conditions
TMJ (Jaw)
Emotion / Memory
Oncology
Headaches
Neurological
Musculoskeletal
Cardiovascular
Family History
Respiratory
Gastrointestinal
Skin
Hearing
Endocrine
Blood
Other Conditions
Prenatal (check boxes to enter details below)
Other
Medical Info
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Review & Agree
Insurance Information

We are able to submit insurance claims to several providers. If you are hoping to bill directly to your benefit provider, please enter the details below to be added to your file.

Please note, in the event that a claim is rejected or in need of further review prior to processing, payment is to be made in full and a receipt will be provided for submission to your extended benefit provider. 

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