By submitting this form, you agree that:
    -You are NOT guaranteed that you will be accepted as a family practice patient at Mavis Medix
    -Your information will be saved in our “Patient Bank”; when a free spot is available, you will be contacted
    -You are responsible to keep your contact information up-to-date
    -You will not provide any personal health information in this form
    -Voice messages can be left at your phone
    -Individuals OLDER than 18 years of age must submit request by themselves NOT by parents