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Get Acadiana Center Occupational Medicine: Demographics And Consent

(Last) Phone: Address: (Address) (City) Age: Social Security #: Employer: (State) (Zip) Sex: Date of Birth: Male Female (If Minor, list Parent s Employer) Emergency Contact: Phone: Preferred Pharmacy: *only if being treated AUTHORIZATION FOR EVALUATION/TREATMENT AND RELEASE OF MEDICAL FORMS I hereby authorize any provider of Acadiana Center to evaluate and or treat the patient. I authorize the release of my medical records to any doctor, employer/employer representative, poten.

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