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Waiver & Health Information for Mini Consult

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Are you taking medication?
No
Yes
Have you had surgery?
No
Yes

© 2023 by Restored Wellness PHA

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