Redline Medical

Patient Intake Form

Requested Information	Input
First Name
Middle Initial
Last Name
Date of Birth
Social Security Number
Address Line 1
Address Line 2
City
State	Please Select State AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY
Zipcode
Email
Current Symptoms	Input Symptoms Here
Problem Location	Head Torso Limb(s) None
Natural Hair Color	Red Not Red
How did you hear about us	Online Physical Ad Saw Our Office Referral Who are you???
How many drinks do you consume per week
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Medical Place for Health	Contact Us	Instagram
PO Box 33112
33 Verstappen Ave