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Get and Sign Pennsylvania Physician Certification Form
__________________________________________________
7. __________________________________________________
physician’s signature
street address
8. _________________
date
9. _____________________________
phone number
___________________________________________________
city
state
zip code
part II: rape or incest - a recipient statement form must be attached
10. This patient is the alleged victim of rape or incest.
Check one box below
o
o
I certify, on the basis of my professional...
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