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Intake Form

If you are seeking medical advice or treatment, please take the time and fill out this form.

**ALL INFORMATION COLLECTED IS CONFIDENTIAL**

Birthday
Month
Day
Year
Multi-line address
Gender
Male
Female
Blood (Type If Known)
O
A
B
AB
I Don't Know
Blood Type RH Factor
Negative -
Positive +
I Don't Know
Multi choice
Do You Smoke?
Yes
No
Do You Drink?
Yes
No
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