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<input name="inf_form_name" type="hidden" value="TOFU - Knee - Info Packet" />
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<div>
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<div class="authoring-image image-snippet" contentid="image">
<div class="imageSnippet-alignDiv">
<img align="bottom" alt="Centeno Schultz Clinic Logo" border="0" class="simage" height="48" src="https://zb434.files.keap.app/zb434/d725c5d4-99a0-4f3c-bde5-d2a27d12cca4" title="Centeno Schultz Clinic Logo" width="385" />
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<label for="inf_field_FirstName">First Name *</label>
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<label for="inf_field_LastName">Last Name *</label>
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<label class="infusion-field-label-container infusion-label-checkbox" for="inf_option_MaywecommunicatewithyoubytextmessageSMSDataratesmayapply">May we communicate with you by text message? *SMS/Data rates may apply</label>
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<label for="inf_custom_Provideanyadditionaldetailsyouwouldliketosharehere">Provide any additional details you would like to share, here:</label>
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<div>
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<label for="inf_custom_ReferralSource">How Did You Hear About Us? *Add Detail if Google / Regenexx Web. *</label>
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<select id="inf_custom_ReferralSource" name="inf_custom_ReferralSource"><option value="">Please select one</option><option selected="selected" value="Please Select One">Please Select One</option><option value="Regenexx.com">Regenexx.com</option><option value="Patient Referral">Patient Referral</option><option value="Previous Patient">Previous Patient</option><option value="5280 Magazine">5280 Magazine</option><option value="Attorney">Attorney</option><option value="Bing">Bing</option><option value="Blog">Blog</option><option value="Community Event">Community Event</option><option value="Daily Camera">Daily Camera</option><option value="Direct Mail">Direct Mail</option><option value="Email">Email</option><option value="Emergency Room / Hospital:">Emergency Room / Hospital:</option><option value="Employer">Employer</option><option value="Facebook">Facebook</option><option value="Friend / Relative:">Friend / Relative:</option><option value="Google">Google</option><option value="LinkedIn">LinkedIn</option><option value="Magazine Article">Magazine Article</option><option value="Newspaper">Newspaper</option><option value="Physician Referral">Physician Referral</option><option value="Provider">Provider</option><option value="Radio:">Radio:</option><option value="Regenexx Corporate">Regenexx Corporate</option><option value="Regenexx Referral">Regenexx Referral</option><option value="Seminar">Seminar</option><option value="Tom Martino Show">Tom Martino Show</option><option value="TV / News Commercial">TV / News Commercial</option><option value="Twitter">Twitter</option><option value="Yahoo">Yahoo</option><option value="Yelp">Yelp</option><option value="YouTube">YouTube</option><option value="Other">Other</option><option value="Didn't Ask">Didn't Ask</option></select>
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<div> </div>
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<div> </div>
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<div>
<div class="text">
<div class="text" contentid="paragraph">
<div>
<span>Insurance may cover office visits, consultations, diagnostic testing, examinations and bracing. However, most insurance does not currently cover Regenexx Procedures at this time.</span>
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