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New Patient Intake Form

Do You Have Medicare?
Do you have health insurance?

Assignment and Release

I, the undersigned certify that I (or my dependent) have insurance and assign directly to Dr. Joyce and New Beginnings Chiropractic all charges whether or not paid by insurance.  I hereby authorize the doctor to release all information necessary to secure the payment of benefits.  I authorize the use or this signature on all insurance submissions.

*New Acupuncture appointments please call P:860.206.8935

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