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*MENS ARX™ will contact you to confirm your appointment after you submit you appointment request. DO NOT UNDER ANY CIRCUMSTANCES use this form to submit any of your healthcare information. You will be provided a HIPAA Patient Healthcare Release form after you have submitted your appointment request. No medical or personal health information should be submitted on this simple appointment request only. We will contact you and provide you with a form packet to be completed prior to setting your appointment or discussing your healthcare needs.