Dr. Chiu's Prospective Patient Inquiry
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I understand that  Dr. Chiu's practice is often full and I will receive a call back if there is potential opening in the practice. 
For urgent or emergent issues, call 988 for mental health crisis support or go to the nearest hospital emergency department.
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Patient Name
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Patient Date of Birth
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Phone Number
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Email
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Insurance Plan and Member ID
Please describe briefly about yourself and the reasons for seeking services. *
How did you hear about Dr. Chiu's practice?
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