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PATIENT REGISTRATION

Street Address, City, State, Zip
In case of an emergency, do we have permission to contact the person listed above?*
I certify that the information provided above is completed and accurate to the best of my knowledge*
Full Name
I hereby authorize Izzy Health PLLC to conduct evaluations, diagnosis, treatment, and/or psychological testing based on the professional recommendations of my psychiatrist. I understand that such procedures provided by Izzy Health PLLC psychiatrists or ancillary staff would be subject to my agreement.
I hereby certify that I am the legal guardian of this patient and legally authorize Izzy Health PLLC to provide mental health care to the above name. I am aware that such care may include evaluations, diagnosis, treatment, and/or psychological testing provided by Izzy Health PLLC psychiatrists or ancillary staff.
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