Yalich Clinic of Glen Burnie

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Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. You MUST SELECT THE MAIN REASON FOR VISIT from the drop down menu in order to provide the DOCTOR or PHYSICAL THERAPIST with your correct health information.

Who are you?

Let's get started. Fill out the fields below to speed up your office visit.