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DiagnosTEX LLC and PLLC MBS Authorization Form Please read thoroughly Patient or Responsible Party must initial all bulleted items and sign at the bottom of the page This signed documents grants the following to DiagnosTEX LLC To proceed with a mobile Modified Barium Swallow MBS study to determine the presence of dysphagia in the oral and pharyngeal stages as well as the thoracic esophagus and cervical spine.

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