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Patient' s Name: Date: As a patient of Arizona Pediatric Surgery and Urology. LTD, I have been informed of the following: It is my responsibility to know if there are any deductibles,

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Page 1: Patient' s Name: Date: As a patient of Arizona Pediatric Surgery and Urology. LTD, I have been informed of the following: It is my responsibility to know if there are any deductibles,
Page 2: Patient' s Name: Date: As a patient of Arizona Pediatric Surgery and Urology. LTD, I have been informed of the following: It is my responsibility to know if there are any deductibles,
Page 3: Patient' s Name: Date: As a patient of Arizona Pediatric Surgery and Urology. LTD, I have been informed of the following: It is my responsibility to know if there are any deductibles,