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Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent

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Page 1: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 2: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 3: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 4: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 5: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 6: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 7: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent
Page 8: Chicago Primary Care Sports Medicine...Chicago Primary Care Sports Medicine 111 N. Wabash Ave., Suite 1919 Chicago, IL. 60602 312-616-7778 Fax: 312-276-4304 PATIENT AUTHORIZATION Consent

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