First Name
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Last Name
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Date of Birth*
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Month
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Day
Year
Age
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Mobile Number
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Email
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Mailing Address
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Occupation
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Type of Employment*
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Employed
Self-Employed
Student
Retired
Desired goals/objectives
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What services are you looking for?
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History of past treatment/therapy/coaching?
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What did you like/dislike about your prior therapy or treatment experience?
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Message
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Cancellation/Refund and Office Policies:
Please note, there are absolutely no refunds for any of your prepaid sessions in case of broken appointments by you as the professional times and days were reserved for you and will be considered as broken appointments.
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I hereby agree to the Office Policies, Payment Policies, Terms and Conditions, the No Refund/No Cancellation Policies, including the required pre-payment for all professional services at Blair Wellness Group.*
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I understand that Blair Wellness Group does NOT accept cash, checks, or insurance, and requires a credit card payment, as well as a valid state ID card to secure all appointments.*
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In accordance with HIPAA and to protect PHI, I understand that BWG requires to speak to all new patients prior to offering an initial consultation. I agree not to submit this form on behalf of any third-party, as it will not be processed.*
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I acknowledge that the scheduling team at BWG are not authorized to respond to clinical questions or repeat information noted on this website during the monitored/recorded telephone calls to avoid misinformation.*
Initials
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