Today's Date (required)
How did you hear about GARM? (required)
Patient Name (required)
Date of Birth (required)
If you are visiting, where are you staying while in Roatan? (required)
Home Address (required)
City/State/Zip Code/Country (required)
Cell Phone (required)
Other Phone (required)
Email Address (required)
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):
Name (required)
Relation (required)
Emergency Contact:
Phone (required)
Tick for Consent For Treatment 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).
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