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7
Questions
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HIPAA
Compliance
1
Full Name
*
This field is required.
Please write first and last legal name
First Name
Last Name
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2
Your Age
13-17
18-30
31+
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3
Phone Number
*
This field is required.
Please enter a valid phone number.
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4
Email
*
This field is required.
example@example.com
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5
Preferred Day(s) of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
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6
Preferred Time of Day
Morning (10:30am-12:30pm)
Afternoon (12:30pm-2:30pm)
Late Afternoon (2:30pm-5:30pm)
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7
Form of Payment
Health Insurance
Private Pay
Bishop (Church) Pay
Other
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