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I, ______Doctor Name____________________, license # ________, by the state of Nevada, have a provider/patient relationship with _____patient name____________ whose medical history I have reviewed and evaluated.
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Document Date: 2015-09-11 20:43:46
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I, ______Doctor Name____________________, license # ________, by the state of Nevada, have a provider/patient relationship with _____patient name____________ whose medical history I have reviewed and evaluated.