Prospective Patients Inquiry Form
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I understand this form is not to be used for urgent or emergent medical or psychiatric concerns. For urgent or emergent issues, call 911 or go to the nearest Emergency Room.
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Patient's name
Patient's age
Patient's location (city and state)
Phone number
Please tell me briefly about yourself and the reasons for seeking services.
Are you seeking treatment with medication, therapy or both?
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How did you hear about Dr. Chiao's practice?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Stephanie Chiao.