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Where did you find us?
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Website
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Who referred you?
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Do you want us to communicate with PCP
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Do you use online scheduling?
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Want access to online portal?
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Which specialists do you see?
• • •
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Diagnosis Given
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What's going on with you?
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How long has this been going on?
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What treatments have you tried?
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Anything else we need to know?
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