GARM Clinic Patient Intake Form

Would you like to receive GARM Clinic's monthly newsletter for health suggestions and updates? (required)
YesNo

Please initial if it is alright to leave a detailed message with health information on your voice mail (required)
YesNo

Parent/Legal Guardian (if the patient is a minor):

Emergency Contact:


I authorize the GARM clinic to perform treatment deemed by the physician, nurse practitioner, physician's assistant, or associate physician in exercise of professional judgment to be of appropriate kind and method on me/my dependent. I agree to pay the remaining balance or the entire bill if necessary. Additional, I understand that some of the services, procedures, and products offered by GARM have not been evaluated, tested, or approved by the United States Food and Drug Administration (FDA).