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(561) 684-9200

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signature(s)

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Sign up using the form or call (561) 684-9200 to make your appointment.

Office Hours

DayOpenClosed
Monday8:30am7pm
Tuesday8:30am6:30pm
Wednesday8:30am7pm
Thursday8:30am4pm
Friday8:30am7pm
SaturdayClosedClosed
SundayClosedClosed

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