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Patient Intake Form

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

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July 8, 2022 1:56 pm EDT

Patient Intake Form Uploaded by Philip Muccio - philipmuccio@axiobionics.com IP 67.193.20.181