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Custodial Parent or Guardian Signature Revised 121714 Date SEC 3 102 PED Pt Information Form Rev 121714. Asst. Initials PEDIATRIC PATIENT INFORMATION FORM All information required. If not applicable please write N/A. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I authorize Spokane Eye Clinic to release any medical information which may be required to determine benefits or process claims...
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