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Lori A. Fitzgerald, DDS, LLC 5711 Shields Road, Suite A, Canfield, OH 444063305330804 PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT / LIMITED AUTHORIZATION & RELEASE
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Begin by entering the date on the specified date field.
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Write your name in the 'Name' field.
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Fill in your complete address in the 'Address' field.
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Specify 'Shields Road' in the 'Street' field.
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5711 shields road suite is the address of a specific location or building.
The entity or individual who is responsible for the location or building at 5711 shields road suite is required to file.
To fill out 5711 shields road suite, you may need to provide specific information about the location or building, such as ownership details or any relevant documentation.
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