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Today's Date
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Last Name
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First Name
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Sex
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Date of Birth
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Address
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Email
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Telephone
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How do you prefer to be contacted?
• • •
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How were you referred to Impact Healing?
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Do you have insurance?
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Responsible Party
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Primary Insurance
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Responsible Party DOB
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Primary Insurance Holder
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Relationship to the patient:
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Primary Insurance Address
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Responsible Party Address
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ID Policy Number
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Employer
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Group Number
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Home Phone
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Telephone
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Work Phone
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Emergency Contact Name
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Emergency Contact Telephone
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Emergency Contact Address
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Payment Authorization
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Insurance Release Authorization
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