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SPINE DISORDERS OF TEXAS PLLC NEW PATIENT QUESTIONNAIRE Todays Date: ___ Name: ___Age: ___ Date of birth: ___ Who referred you to our office? ___ When did your problem start? ___ Instructions: Only

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Spine Disorders of Texas is a medical clinic specializing in the diagnosis and treatment of spine-related issues.

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Patients must report their personal information, medical history, insurance information, and details of any treatment received at Spine Disorders of Texas.

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