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Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Best Time To Call:
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Email:
Group Name:
Number in Group:
(Refer to guidelines for group limits.)
Services:
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Description of services (ex. music, beauty, massage, etc.) to be provided to patients. Please be specific.
Benefits:
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How will the patients benefit from your visit?
Date of Visit:
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When are you interested in visiting?
Agreement:
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I verify that I have read and agree to follow all Arts and Healing visitor guidelines. I understand that each member of the group will be asked to sign this form on the day of visit prior to providing services.
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