OPTM Therapy | Intake Form
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INTAKE FORM

PERSONAL INFO

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Emergency Contact

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Employer Info

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I authorize release of information requested by my insurance plan for payment.
I understand that I am financially responsible for any balance due.
I agree to comply with the terms and conditions as outlined on the Patient Registration Form.
I hereby acknowledge that I have received a copy of the Notice of Privacy Practices.

By checking this box you agree to the above terms.
I agree

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