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// Medical Intake

Tell us about you.

Confidential. Florida residents only. Takes about 5 minutes.

SERVICE

FULL NAME

EMAIL

PHONE

DATE OF BIRTH

STATE

HEIGHT (INCHES)

WEIGHT (LB)

CURRENT SYMPTOMS

CURRENT MEDICATIONS & SUPPLEMENTS

RELEVANT MEDICAL HISTORY

I confirm I am a Florida resident, 21 years or older.I consent to receive care via telehealth and understand cash pricing (insurance not accepted at this time).

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