New Patient Registration | Health and Healing

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New Patient Registration *

Parent First Name

Parent Last Name

Parent Date of Birth

Parent relation with child *

Father

Mother

Other

Child First Name

Child Last Name

Child Birthday

Child Sex *

Male

Female

Phone Number

Email

I agree that health an healing pedatrics may contect me via phone ( call/text) and emal for doctors offce related communications

Select an Address

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