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COVID -19 Message: All patients and visitors will be temperature checked and screened prior to entering the office.

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Please fill out the form below and we will get back with you within 48 buisness hours.

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Date of Birth

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Are you interested in Adult or Pediatric Studies?

Adult

Pediatric

Adult & Pediatric

Are you currently suffering from a medical condition, illness, or injury?

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Yes

If you answered yes to any question, please elaborate

What is the best time contact you?

8am -1pm

1pm-6pm

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