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Patient Responsibility Form Kristie B. Rosser APRN FNP-C Optimal Wellness Date KayRoss Education INC. Who Provides your insurance Self Spouse Mom Dad Marital Status Single Mar Div Wid Sep First Middle Last Spouse DOB // Address City State Zip Email C Phone-- Employer Occupation Work Address How did you hear about us Clinic If it was a Doctor or Patient please give their name Please give Clinic name Responsible Party Please check if this is you Emergency Contact not living with you...
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