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Foundation Chiropractic Clinic 1515 S. Byrne Rd, Suite 106 Toledo, OH 43614PAIN DRAWING Name: ___ Date: ___ Please be sure to fill this out extremely accurately. Mark the area on your body where you
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Dr. Michael Jajuga DC is a chiropractor.
Patients who have received services from Dr. Michael Jajuga DC may be required to file.
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The purpose is to document the services received by a patient from Dr. Michael Jajuga DC.
The information reported includes the date of service, type of service provided, and any payments made.
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