Rachel Porter (Revive Therapeutics)

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Rachel Porter (Revive Therapeutics)

Client Information
Male Female Other

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

Select the reason for seeking care
Wellness (relaxation, stress reduction, or performance enhancement)
Treatment (pain, injury, medical condition, pregnancy)

Note: You will be given additional intake forms to complete based on your condition and current needs.

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