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Travis Dietrich. D.C. 903 South 17th Ave. Suite D Wausau, WI 54401 715.845.6800 www.MyWausauChiropractor.comAdult Intake Form Personal Information Date: Name:Date of Birth://Age:Male / FemaleAddress:

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Travis Diederich DC Wausau is a chiropractic clinic located in Wausau, Wisconsin.

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Patients or individuals who have received services from Travis Diederich DC Wausau are required to file any necessary paperwork or claims related to their treatment.

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