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WINE COUNTRY DERMATOLOGY BRENT LOFTS DO, INC. REGISTRATION/CONSENT FORM Today's Date:PATIENT INFORMATION Last Name:Is this your legal name? Yes First Name:Middle Initial:If not, what is your legal
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Brent Loftis Do Inc is a corporation providing medical services.
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The purpose of Brent Loftis Do Inc is to provide medical services to patients.
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