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Rachel Porter (Revive Therapeutics)


Personal Information
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Text Messages (optional)

I CONSENT to the practice contacting me by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up-to-date mobile number at all times, or if the number is no longer in my possession.



Emergency Contact

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Wellness Intake
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Billing and Insurance Information
Referring Healthcare Provider

Primary Insurance Provider
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Attorney

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