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OFFICE VISITS
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Consultations
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Referring Doctor
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WELL EXAM NEW PATIENT
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WELL EXAM EST PATIENT
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Risk LowZ12.4 High
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OBSTETRICS
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INJECTIONS
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Other
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MISCELLANEOUS
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PROCEDURES
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CONTRACEPTION
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Bill for IUD product?
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MISC PROCEDURES
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If Exr.Benign lesions/trunks/arms/legs- what cm?
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If Exr. Lesion/ genitalia- what cm?
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ULTRASOUND
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PELVIC
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PREGNANCY
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LABORATORY
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Other
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Diagnosis
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1st
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2nd
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3rd
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Trimester
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INSURANCE
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CO-PAY for Today $
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Please Select
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Other
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RETURN IN
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DAYS
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MONTHS
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WEEKS
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YEAR(S)
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PAYMENTS
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CASH $
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CHECK#
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CREDIT CARD $
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DEPO
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Select
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Ultra Sound
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Select
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REFER TO
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