I understand, have read and completed this questionnaire truthfully. I agree that this constitutes my full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or hospitalization. I also understand that if any of my personal information has changed, I must inform the front desk. If I do not inform the practice about changes in my address, financial status if being charged based on the financial hardship form, etc, I will be held personally responsible for payment for service. I will also give the office 7 days notice if I am running out of medications and don't have an appointment scheduled.
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