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Get Affinity Health Clinic Chiropractic Intake Form

__ City: ______________________ Prov. __________________ Postal code ____________________ Home Phone: ______________________________________ Cell ______________________________ Work Phone: ___________________________ ext. ___________________ Fax _______________________ E-mail: ___________________________________________________________________________________ Birth Date (dd-mm-yy): ________________________________ Shoe Size: _______________________ Height: ________________________________ Weight.

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