VIP Form

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The RiteCare For Your Employees Basic Walk-In Visit $99

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    Client Information


    Worker's Comp Insurance

    Billing Information


    *Please note a separate Credit Card authorization form is required

    Drug Screen

    Does your company require a mandatory drug-screen after any work-related injury?



    Reports


    Would you like a weekly or monthly status report for patients?


    Additional Information




    Additional Information



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