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Waiver and Health

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Schedule an appointment
December 2025
SunMonTueWedThuFriSat
Week starting Sunday, December 7
Time zone: Coordinated Universal Time (UTC)Phone call
Monday, Dec 8
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
12:00 PM - 1:00 PM
1:00 PM - 2:00 PM
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