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4911 LC Eye Clinicadmin2020-12-17T23:14:28+00:00

4911 LC Eye Clinic

  • Patient Information

  • MM slash DD slash YYYY
  • CellHomeWork
  • GradeSchoolTeacher 
  • Insurance Information

  • I understand that I am responsible for payment of any charges not covered by my insurance. I authorize payment of healthcare benefits to this clinic. I also authorize release of any medical records necessary to process any claims.
  • Signature of Patient/ Guardian
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