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Jeffrey M. Smith M. D. 161 Date Street Escondido CA 92025 Tel 858-278-8031 Fax 858-278-1708 Orthopaedic Traumatologist Board Certified in Orthopaedic Surgery REGISTRATION INFORM ATION PVT PPO M-CAL M-CARE HMO CHAMPUS Date CASH Patient s Full Name Last First Address Hm Phone Marital Status Middle City Wk Phone Date of Birth State Other Age Billing Address Email Sex Social Security Employer Zip Occupation Referred By Primary M. I accept financial responsibility for all charges incurred. I...
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