FORM A) PATIENT REGISTRATION FORM
By submitting this form, you agree that:
-You are NOT guaranteed that you will be accepted as a family practice patient at Mavis Medix
-Your information will be saved in our “Patient Bank”; when a free spot is available, you will be contacted
-You are responsible to keep your contact information up-to-date
-You will not provide any personal health information in this form
-Voice messages can be left at your phone
-Individuals OLDER than 18 years of age must submit request by themselves NOT by parents
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