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Patient Intake & Consent Form

Address:1278 Shillington Ave., Ottawa, ON, K1Z 8A4

Tel: 613-710-9555

Birthday
Year
Month
Day
Gender
I understand and consent that the therapist will need to touch and do treatment on lower back and/or buttocks area if I I have problem at lower back area.
I have read the full consent from the link above. I (or the substitute decision-maker listed below) consent for the practitioner to collect, use and disclose my personal health information for the purpose of providing treatment needed.
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