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Medical Services Agreement

Medical Services Agreement

Medical Services Agreement

Date:

Patient Information

Patient Name:
Date of Birth: Patient DOB

Agreement

I acknowledge that I have read and understand the terms of this agreement.

I agree to the terms and conditions

Signature

Patient Signature: (Sign below)

Date:

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.