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CONFIDENTIAL HEALTH INFORMATION Gray Family Chiropractic PLLC Dr. Stacy C. Gray D.C. CACCP Please allow our staff to photocopy your driver s license and insurance details. Endocrine Thyroid issues i. Genitourinary Kidney stones Immune Hypoglycemia Infertility Bedwetting Frequent Prostate issues Erectile dysfunction j. What would be the most significant thing that you could do to improve your health Patient or Guardian s signature Date MM/DD/YYYY 4/4 Back Index ACN Group Inc. Form BI-100 ACN...

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