SOUTHEAST DERMATOLOGY, PA
I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
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I have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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