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Health History Intake Form
This will help us get a comprehensive health history and expedite your clinic evaluation time. Form completed by (if other than patient):
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PEDIATRIC PATIENT INTAKE FORM (AGE UNDER 14)
I, the undersigned, for myself or another person for whom I have authority to sign, hereby consent to dental care and treatment while such care and treatment is
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PATIENT INTAKE FORM
Consent for Treatment: I request Elica Health Centers (EHC) to provide me with medical, dental, behavioral health (substance abuse, psychological, or
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