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The contracted Clinic/Centre shall receive payment for all such tests carried out. Name of doctor or nurse BLOCK CAPITALS Male Female Clinic/Centre Name Please specify Assistant Doctor Registered Nurse Medical Council Registration Number MCRN or Nursing Midwifery Board of Ireland Number NMBI Signature of the Qualified Person Date Clinical Director Name BLOCK CAPITALS PCRS / GMS Number of Clinic/Centre Signature of Clinical Director Programme Administration Office of any changes to your...

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