subject_line
Consultation Request for Dr. Darcy Dane
Patient First Name
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Patient Last Name
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Age
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DOB
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Current grade if in school
Name & Relation of person to contact if you are filling this out for someone. (e.g. Sally Seashore, mother)
Street Address
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Address Line 2
City
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State
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Texas
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Vermont
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West Virginia
Wisconsin
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Washington DC
Zip Code
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Phone Number
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Email Address
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Please list your top 4 health concerns.
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Have you been treated for this/these condition(s)?
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Yes
No
Were you satisfied with the results of your treatment?
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Yes
Somewhat
No
If you were only somewhat satisfied or not satisfied, what would have made your experience better?
How did you hear about our office? For our referral program, please enter the name of our patient who referred you next to other.
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CBS17 Carolina Experts.
Radio Ad
Midtown Magazine
Word of Mouth
Facebook
Referral
Google
Other/Patient
Other/Patient
If you were referred by a physician please choose from the following list
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Not referred
Dr. Will Pendergraft
Dr. Julie McGregor
Dr. Bobbie Barbrey
Dr. Angela Baylis
Dr. Karen Carrick
Dr. Beverley Goode
Dr. Jeff Hanschumacher
Dr. Lindsay Mumma
Dr. Mackenzie Smith
Dr. Elizabeth Sierakowski
Dr. Rebecca Jackson
Dr. Linda Orlasky
Dr. Shawn Phelan
Dr. Matthew Wilding
Dr. Samuel Yanuck
Dr. Sonia Rapaport
Dr. Kris Jonasson
Chiropractor
Pediatrician
Primary care physician
Psychiatrist/Psychologist
OT/PT/Speech therapist
Not listed
If your physician was not listed please provide their name.
Preferred Contact Method
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Phone Call
Email
Text Message
Due to the constraints of working as a provider for an insurance company, Dr. Dane has elected not to participate in any insurance programs. There is no reimbursement available for treatments or services. Payment is expected at the time of service.
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I have read the above statement.