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This is a direct assignment of my insurance benefits. This payment will not exceed indebtedness to the providers at Everett Spine Rehab. 927 128th St. SW. Suite B Everett WA 98204 P 425 347-8614 F 425 348-6986 www. everettspinerehab. com NEW PATIENT INTAKE FORM PATIENT INFORMATION PATIENT CONDITION Name Reason for visit Sex M F Age When did your symptoms appear Birthdate Is your condition getting worse Yes No Address Mark X on the picture where you continue to have pain numbness or...
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