​NEED A FORM COMPLETED

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Forms will only be accepted once ALL of the following has been completed by the patient. ​

All other requests will be returned until completed. 

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1. Please complete the patient section with your name and other demographic information

2. Please sign patient consent portion of form

3. Please complete a draft copy of the physician section with what you would like your physician to know

4. Please make sure you have read the form from TOP  to BOTTOM

5. You agree to pay requested fee for form. Please visit uninsured services. Fees may very depending on the complexity of the form and whether you have a PS365 annual plan.

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I agree I have read and completed the 5 criteria above and would like to upload my form  ​