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I fully release and discharge Dr. Melissa Tonn and Kroger Texas L.P. DBA Kroger Pharmacy its affiliates and their officers directors and employees from any liability for illness injury loss or damage which may result there from First Name print Middle initial Last name Street address City State Zip Code Phone Date of birth Sex M / F Family Physician First and Last Name Physician Address City Physician Telephone Number if applicable Allergies Chronic Disease Are you between the ages of 12 and...
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