Patient Forms

To make your visit as fast and easy as possible, we’ve provided a number of options for submitting them:

Print and bring the filled in forms with you to your first visit.
Complete and submit the forms through our Patient Portal.
Fill them out at the time of your visit with the assistance of one of our staff members.

First NAME^*	Last NAME^*
EMAIL ADDRESS*	PHONE NUMBER*
city	State
Why are you interested in owning an Emediate Cure clinic...
Do you have $150,000 without a bank?YESNO

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