div class=ts-pagebuttonPage 1button div class=ts-image amp-img class=ts-thumb alt=Page 1: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails1jpg width=142 height=106 layout=responsive amp-img divdivdiv class=ts-pagebuttonPage 2button div class=ts-image amp-img class=ts-thumb alt=Page 2: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails2jpg width=142 height=106 layout=responsive amp-img divdivdiv class=ts-pagebuttonPage 3button div class=ts-image amp-img class=ts-thumb alt=Page 3: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails3jpg width=142 height=106 layout=responsive amp-img divdivdiv class=ts-pagebuttonPage 4button div class=ts-image amp-img class=ts-thumb alt=Page 4: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails4jpg width=142 height=106 layout=responsive amp-img divdivdiv class=ts-pagebuttonPage 5button div class=ts-image amp-img class=ts-thumb alt=Page 5: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails5jpg width=142 height=106 layout=responsive amp-img divdivdiv class=ts-pagebuttonPage 6button div class=ts-image amp-img class=ts-thumb alt=Page 6: · Phone 561498-5660 Fax 561498-0753 Patient Signature: Date: New Patient Intake Form Consent For Treatment Authorization to Release Information I print your name voluntarily src=https:reader034vdocumentssitereader034viewer20220502155f614a62c4d10c067d51580ahtml5thumbnails6jpg width=142 height=106 layout=responsive amp-img divdiv