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Get FOTO Patient Intake Survey Foot Ankle Lower Leg Without

FOTOPatientIntakeSurvey Foot,Ankle,LowerLeg(withoutknee) StafftoComplete PATIENTNAME: PatientID: Gender:Male/Female DateofBirth: / / Clinician: BodyPart Impairment CareType PayerSource (TypeofPlansuchasPreferredProvider,HMO,WC,AutoInsurance,etc.).

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