PLEASE NOTE > All appointments must be confirmed prior to arrival.

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Patient Intake


Please email the answers to the following intake questions to prior to your appointment: 

Full Name:

Preferred Salutation: 


Date Of Birth: 

Mailing Address: 

Email Address: 

Mobile Number: 

Emergency Contact: 

Drug Allergies: 

Current Medications: 

Medical History (ex. High Blood Pressure): 

Primary Care Doctor: 

Reason For Visit: 

Email for Payment: 


Contact our office if you have any questions! 

What we offer



iClinic Atlanta
2531 Briarcliff Rd., Suite 211
Atlanta, GA 30329
Phone: 678-732-0193

Office Hours

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