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Patient Name DOB / / Payment for services is expected and due at the time of your visit. Please acknowledge acceptance of this policy by your initials and signing and dating the form below: Initials
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Signature on file pagedoc is a document that contains a pre-approved signature that can be used for multiple transactions or agreements.
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The information that must be reported on signature on file pagedoc includes the individual's name, date of birth, and relevant contact information.
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