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__________________________ Address:___________________________________________ City, State, Zip __________________________________ Home Phone #: ______________________ Work: ________________________ Cell: ____________________________ Occupation: ________________________________  Please check here if we can email you updates and a newsletter. Marital Status:  M  S  W  D Height: ________ Weight: ________ Allergies: ____________________ Emergency Contact Name:________________________.

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The following tips will help you complete Acupuncture New Patient Intake Form easily and quickly:

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  3. Press the green arrow with the inscription Next to move on from one field to another.
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  5. Insert the date.
  6. Look through the whole document to ensure that you have not skipped anything important.
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