Kelly Avenue Medical Clinic | D2Type

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Patient Intake Form

This form is part of a HIPAA-compliant workflow. Information is encrypted and handled in accordance with applicable healthcare privacy regulations. Please share only the minimum necessary information. [View Privacy Practices]

First Name

Last Name

Preferred Contact Method Required

Email

Phone

Email

Phone Number

Clinic Name

Kelly Avenue Medical Clinic

I consent to share the information above with D2Type Health Inc. and allow D2Type to contact me for onboarding and support.Privay Policy

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