New Client Intake Form for Dr. Rhiannon Hutton, DC, MAOM, LAc
Health Privacy Information Act Compliant Form
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New Patient Intake Form
This form is in compliance with the Health Privacy Act. Your information will be sent over the internet. We suggest using a trusted network when submitting health information. *
Patient Name *
Patient Address *
Phone Number *
Email (For office use only) *
Patient's Date of Birth *
Patient's Age
Emergency Contact Name *
Emergency Contact Phone Number *
In which areas of your life would you like to improve/ do you want more? Ie. Career, relationship, finances? Please elaborate below. *
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