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WIS X-Ray Patient Information Form

PLEASE NOTE: The data you enter below is fully secure, encrypted at rest using 256-bit AES encryption, and accessed over HTTPS (SSL) 100% of the time for HIPAA compliance. If you need to save your progress, click “Save” at the bottom and return within 7 days using the link that is emailed to you. Please complete prior to your appointment to expedite the check-in process.

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