Please complete registration form below. If you have insurance, please bring insurance card to your appointment.

Patient Information
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  6. (required)
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  8. (required)
  9. (valid email required)
  10. (required)
  11. (required)
  12. (required)
Medical History
  1. a. Illnesses: Select any that apply





Family Medical History
  1. Select any that apply


Insurance Information (If applicable)
Emergency Contact
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  1. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Healthy Living Medical or insurance company to release any information required to process my claims.
  2. (required)
  3. (required)
 

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