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Meet the Doctors: Naturopathic Physician and Chiropractor
Natural Medical Care & Treatment
Scientific Quantum Long Distance Energy Healing
Forms, Payment & Contact
Intake for First Telemedicine Visit
Date of Birth
Spouse/Partner’s Full Name
NEAREST LIVING RELATIVE **(SOMEONE OTHER THAN YOUR SPOUSE/PARTNER)**
Relationship to Patient
Who Referred You?
Who Is Your Primary Care Physician?
Were you in an automobile accident in the last 12 months?
If so, when?
With whom may we discuss your medical information (i.e. spouse, children, friend, other relative)?
The law requires that we provide to the patient a copy of our Notice of Privacy Practices for health information. By signing below, the patient acknowledges receipt of such, or if you are the patient’s legal representative or authorized agent, you acknowledge receipt of such.
Scientific Quantum Remote Healing
Intake for First Visit
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