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Lifestyle Management Therapy                                      


 

The next step is to fill out our new patient forms and request your first appointment.

 

Name   

Address  

City

StateZip Code

Phone Email

Best Time to CallRequested Appointment Date & Time

Services Requested

Health Insurance Company  

Insured ID

Date of Birth

Health Insurance Provider Phone Number

Health History

Medications

Surgeries

Family History

Offer Code

If you don't hear from us within 24 hours, call us at 800-801-8769 or 602-358-8883

I hereby give permission to the doctor to release any information requested by my insurance company acquired in the course of my examination and treatment.  I hereby authorize and direct my insurance benefits to be paid directly to the doctor.  I am financially responsible for all non-covered services.  I hereby give permission to the doctor to administer treatment and perform general procedures as he may deem necessary in the diagnosis and treatment of my condition.  I have read, understand and agree to the above.  I also understand that by pressing the submit button below, I am affixing my electronic signature. 

 

 

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