Please fill in additional patients.
reason:
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Illness
Injury
Physical
Vaccination/Injection
COVID-19
The clinic has reached its limit for this visit reason today.
Patient First Name
Patient Last Name
Email
Cell Phone Number
Date of Birth
Patient Birth Sex
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M
F
Text me a link to complete my registration.
I'd like to leave and come back. Hold my spot and send me a reminder text.
minutes before your visit
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