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Let's get to know you
How can we reach you?
Who can we reach during an emergency?
How will you be covering your visit?
Are you experiencing any of the following symptoms?


Medical History

Reason for Testing
Permissions: I give permissions for the following:
May we phone, email, or send a text to you to confirm appointments?
May we phone, email, or send a text to you to confirm appointments?
May we discuss your medical condition with any member of your family?
Consents
I want to receive information to access my results and health data online through patient portal.
I consent to share my immunization record with a state registry.
I consent to the clinic pulling my medication history to best treat me.
I consent to the clinic sharing my health data with a Health Information Exchange.
Please upload valid IDs so we can verify that we are seeing the right person.