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NEW PATIENT REGISTRATION

MEDICATIONS AND PRESCRIBERS

**Please Provide Accurate and Complete Contact Information**

We Will Not Obtain the Information for You

!! DON'T FORGET !!

 

YOU MUST PROVIDE PROOF OF INCOME

UNLESS OTHERWISE DISCUSSED WITH YOUR PATIENT ADVOCATE, PLEASE PROVIDE A COPY OF YOUR MOST RECENT TAX RETURN FORM 1040 (page 1 - 2).  OTHER ACCEPTABLE FORM OF POI ARE MOST RECENT W-2's, 1099's, or 30 DAYS CONSECUTIVE PAY STUBS.

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