31 N. Lansdowne Ave, Suite 203, Lansdowne, PA 19050
(located inside The Historic Lansdowne Theater)
(Ph) 844.578.7713 (Fax) 844.567.4413
*Clients under the age of 18 need to complete this form with a parent or legal gaurdian.
C. You Medical Care
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
I. Health & Mental Health Information
J. Emergency Information
If some kind of emergency arises, whom should we call?