We hope you come back another time

We are sorry you had to cancel your visit, but we are grateful you let us know. We hope to see you in the future.
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USED TO SET NEW REGISTRATION FLAG
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Patient Named on Visit(Required)
MM slash DD slash YYYY
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the hidden value of the url code for the clinic selected. USE THIS FOR ALL SELECTION OF CLINIC
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the hidden value of the url code for the clinic selected. USE THIS FOR ALL SELECTION OF CLINIC
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hideme {current_hour}
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HIDE ME
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If this is not correct - please go into the clinic and check with the front desk
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Patient Name
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MM slash DD slash YYYY
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MM slash DD slash YYYY
captures the date of entry for use in calculations
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MM slash DD slash YYYY
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