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New Patient Intake Form
Were you referred?
Which of the following do you have in you bedroom? Required
Do you eat breakfast?
Does your breakfast contain protein?
Do you eat lunch?
Is dinner your main meal?
Do you smoke marijuana?
Do you wake up at night?
Do you smoke cigarettes?

This is a consultation you have requested, any recommendations are not meant to take the place of medical advice, diagnosis. or treatment. All information provided will not be shared with any individual or organization without the patients acknowledgment or consent. If you have questions about physical health, please consult your family practice doctor. 

Thank you for submitting. We will contact you shortly.

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