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Get and Sign WE ARE HONORED YOU CHOSE US to EVALUATE YOUR CONDITION  Form

Get and Sign WE ARE HONORED YOU CHOSE US to EVALUATE YOUR CONDITION Form

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Responsible for this account Name of person on your health insurance card Name of their employer Employer Phone Children Names Ages In case of emergency whom should we contact Phone FAMILY PHYSICIAN What is your primary complaint IS THIS WORKMAN S COMPENSATION IS THIS PERSONAL INJURY Patient Informed Consent I the undersigned patient consent to the treatment s provided by this clinic. I understand that my condition may necessitate modifications from time to time of the type of treatment s...
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