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Physician s or Authorized Representa ve s Signature DATE Print or Stamp Name of Physician Print Pa ent s Name If Representa ve Print Name and Rela onship To Pa ent. It is the intent of this agreement to apply-to all medical services rendered any me for any condi on. Ar cle 6 Retroac ve E ect If pa ent intends this agreement to cover services rendered before the date it is signed including but not limited to emergency treatment pa ent should ini al below ini al Pa ent s or Pa ent s Representa...
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