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404-953-0001

Tues - Sat  8:00am - 5:00pm

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Service Consent Form

Birthday
Month
Day
Year
Hospitalized in the last 12 months?
Yes
No
Medical condition, illness, or injury?
Yes
No
Medical History: Which Applies?
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You may Contact our Local Health Authority with any concerns or emergencies at 678-610-7469

You Will be Redirected to the Homepage Once it's Submitted

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