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Get IA Form 19 2015-2024

Middle, last Health Care Provider Statement in Lieu of Testimony (and Attorney Certificate) vs. Defendant Full name of Defendant: first, middle, last Patient Name: Type of Incident: Date of Incident: Answer the following questions with information and opinions regarding the named patient. Check this box if you are attaching separate pages for any of your answers to the questions below. Be sure that the question to which your answer relates appears at the top of each additional page. Number.

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