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Scheduling Appointment Form

Patient Information

Appointment Information


Clinic Hours

Disabled/grayed out time slots are already booked.

Patient Screening Form

Do you have any of the following?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Do you have any problems in the following situations?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No Unsure
Yes No
I have read and agree to the HIPAA, Privacy Practices & Terms and Conditions that follows all state & federal HIPAA laws.