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If you are a new patient or an existing patient, who's information (address, phone #, medical history) had changed since your last visit, please fill up this form.
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Please sign this form as an aknowledgement of your financial responsibility for insurance non-covered charges.
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This form is to let us know how you would like to be contacted or to whom may we disclose your information (e.g. spouse, sister/brother, etc.).
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Please fill up this form if you need us to transfer your records to another doctor (allow us 48 hrs to respond) or if you want your other doctor to send your records to us.
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