MyHealthPointe Email Form

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Welcome

Hi there, please fill out and submit this form to enroll in the myHealthPointe Client Portal.

6Questions

1
Client's Name
First Name
Last Name
2
What Location is the Client Being Seen
Plattsburgh Area
Glens Falls Area
3
Email
example@example.com
4
Client's Birth Date
Date
Year
Month
Day
5
Are you the client?
YESNO
6
If Not...what is your name and relationship to Client?
Should be Empty:

Question Label

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