Patient Waitlist
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First Name
Last Name
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Date of Birth
Phone Number
Email Address
Street Address
Important Disclaimer
Completing this form places you on our waitlist to become a patient at Vivo Family Medicine.  When spaces are available, we will phone you for an intake appointment. You will only become a patient at our clinic after attending the intake appointment.  
Family Members
We ask you to kindly re-submit the form for each family member so that we have the necessary information to register you and your loved ones into our clinic.
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This form was created inside of Vivo Family Medicine.