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Signature Patient/Parent/Person Financially Responsible Acct Updtd Ins Updtd Date Comments Updtd Scanned Rev 11/10. Fees for special medical reports are payable in advance. Charges for accidental injury are payable at the time of service regardless of any pending litigation or settlement. Thank you for selecting our Cornerstone family. If you have any questions or need assistance we will be happy to help. Patient Information Confidential MRN Name Home Phone First Middle Last Goes By/Nickname...
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