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 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
ELECTRONIC SIGNATURE
* ELECTRONIC SIGNATURE    By entering my email address or home address in this box, I am signing this Practice Orientation Agreement and Coordination of Care. I hereby certify that I am either the client as entered above or a parent/legal guardian for the client. I agree to the terms and conditions set forth in this agreement. My signature below indicates that I consent to receive services at Wentworth & Associates, that I understand I may discuss any questions I have regarding services, and that I maintain the option to terminate my consent at any time. I have been re-oriented to the practice and understand my rights and responsibilities as a client.
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