GOLFLETICA Sports and Rehab

Patient Intake Form

*Please contact the clinic (425-221-7253) BEFORE completing this New Patient Intake Form. You must have an appointment scheduled first. ************************************************************************************* Junior National Team Members** Please complete as directed but you may skip the following sections: Insurance Information (-Leave Blank), Referral Information (-Leave Blank), Reason for Visit (-If you do not have an injury or areas of concern, choose "Other", complete the rest of the sections and make sure to sign at the end. Don't forget to his SUBMIT.

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