First Name
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Last Name
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Birth Date
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Month
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Day
Year
Date
Street Address
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City, State, Zip Code
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Best Phone Number
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Email
example@example.com
Height / Weight
Employer Information
The average American spends 40% of their life at work. It's important to us to understand what you do and who you do it with.
Your Occupation
Employer
Emergency Contact
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Emergency Contact Phone number
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Acknowledgements
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I have read and reviewed the Privacy Policy (https://www.enviveonline.com/privacy-policy/) and understand it describes how my personal health information is released on my behalf for seeking reimbursement from any involved third parties.
I realize that an x-ray may be hazardous to an unborn child and I certify that to the best of my knowledge, I am not pregnant.
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails, or health information to me as an extension of my care in the office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.
I may request a copy of the Financial Policy at any time.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
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How Can We Help You?
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