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Get CareMount Medical Informed Consent For Radiology Procedure Or Intravenous Contrast 2016-2024

Onah 111 Bedford Road Katonah NY 10536-2115 914-864-4505 Poughkeepsie 2507 South Road * Route 9 Poughkeepsie NY 12601-5465 845-471-2287 Mount Kisco Imaging 34 South Bedford Road Mount Kisco NY 10549-3408 914-242-3200 INFORMED CONSENT FOR RADIOLOGY PROCEDURE OR INTRAVENOUS CONTRAST Patient Name: Birthdate: NextGen# I hereby request and authorize Dr. and / or associates or assistants of his / her choi.

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