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The Potter's House of Dallas 

 COVID-19

Testing - Registration

Please fill out survey to register / Favor de llenar formulario para registrarse 

Patient information / Información del paciente

Please fill out one form per person / Favor de llenar una forma por persona

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Race/Ethnicty / Raza/Etnia
I consent to be contacted by HHLB, LLC regarding any marketing solicitations including but not limited to preventive visits, new services, offers and/or promotions. I hereby give my consent to be contacted via the following methods: / Doy mi consentimiento para ser contactado por cualquiera de los siguientes metodos, para mercadotecnia, visitas preventivas, nuevos servicios, ofertas, y/o promociones: Required

CONSENT AND AUTHORIZATION FOR COVID-19 RAPID ANTIGEN TESTING 

Click Here / Haga click aquí

 

English: Consent Form

Spanish: Formulario de consentimiento

© 2023 by Hormone Harmony Life Balance, LLC

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