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Patient Referral
Patient Referral
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Name
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First
Last
Presenting Problem
Chronic Infection
Chronic Fatigue
Immune Disorder
Cancer
Weight & Metabolic Complaints
Insulin or Leptin Resistance
Chronic gut issues or SIBO
Other
Treatments Requested
Naturopathic Consultation
H.O.C.A.T.T
HBOT
Kinesiology
PEMF
G-Force (Hypervibe)
Rectal O3
Specific Comments
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