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To complete and submit our 'Wellness Questionnaire' privately online,
click here.

Otherwise, please click the PDF icon below to download and complete a
fillable PDF form and then print and FAX it back to the number below.

Fax: 602-532-7690



Your careful completion of our health history form helps us customize care options specific to your needs. 

If you are uncertain of how to answer a certain question, just make a note of it in any of the comments sections

and we will address it during our consultation.

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