All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

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Primary Language
Marital Status
I Have No Insurance
Patient Communication Consent: We may need to contact when you are not in the office. This is to acknowledge that you authorize us to: <br><br>Leave a detailed message on voicemail.
Leave a detailed message with individual answering the phone.
Email you using an encryption software.
Text you. You understand that standard charges will apply through your mobile carrier.