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Ursula Marquez, EAMP


*Print, complete, sign and date the forms. 
Then bring with you for your first visit along with your insurance card and driver's license.

We request you print these forms SINGLE-SIDED only. 
Please do NOT print double-sided.

Acupuncture new patient intake forms....[print, complete, date & sign all forms]

HIPPA Privacy statement....[This is provided for your review.  Printing is optional.]



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