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Comprehensive Care Appointment
Fill out the form in its entirety. If you need help, give us a call at (803) 849-8434.
***Please note: you must fill out all sections and submit the form in order for your appointment to be scheduled.***
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Email
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Your email
First and Last Name
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Your answer
Gender
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Male
Female
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Other
Race
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Black/African American
White/Caucasian
American Indian / Alaska Native
Asian
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Biracial
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Main Phone Number (include area code)
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Your answer
Alternate Phone Number (include area code)
Your answer
Date of Birth
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Street Address, City, State, Zip Code
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Your answer
Have you previously attended our facility?
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If you have previously attended our facility, what were you seen for? If you have never attended, enter N/A
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Your answer
Do you have a primary care physician?
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If yes, who is your primary care physician? If no, enter N/A
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Your answer
Do you need assistance in acquiring health care coverage?
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