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Personal Information

In the event that evening availability becomes limited in my appointment calendar, please indicate below if you have any flexibility for daytime appointments or Saturdays (Be Specific on which days/times)

***Please note: Email correspondence is not considered a confidential medium of communication

Personal Health History

Please identify any concerns in the following areas:

Family History

In the section below, identify if there is a family history of any of the following: If yes, please indicate the family member’s relationship to you in the space provided (e.g. maternal Aunt, paternal grandfather, etc.