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media.50below.commedia.50below.com/organizations/3afeeae8-5b36-4f6d-b3e7-c00e250e... · Physician's Name (printec and legible) and phone number Physician's Signature & Date (stamped

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Page 1: media.50below.commedia.50below.com/organizations/3afeeae8-5b36-4f6d-b3e7-c00e250e... · Physician's Name (printec and legible) and phone number Physician's Signature & Date (stamped
Page 2: media.50below.commedia.50below.com/organizations/3afeeae8-5b36-4f6d-b3e7-c00e250e... · Physician's Name (printec and legible) and phone number Physician's Signature & Date (stamped