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Medical Case File Template Form
Facitlity> and its employees, associates, and agents free and harmless
from any and all liability whatsoever that may arise from the release of such information to the
said attorney or any person designated by the said attorney.
I agree and understand that upon my initial visit to for treatment or examination, I am
obligated to pay an initial partial payment to and that the balance thereof shall be paid in monthly
installments to I fully understand that I am primarily and personally liable for...
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