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CARRELL CLINIC CENTER, TOWER 1 SUITE 410, 9301 NORTH CENTRAL EXPWY. DALLAS, TEXAS[removed]CIVA CT IMAGING | CT SCAN PATIENT QUESTIONNAIRE Name: ______________________________________ Date of Birth: ______________ Sex _____
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Document Date: 2010-02-18 22:55:25

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File Size: 203,75 KB

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City

DALLAS / /

Company

Insurance Co. / /

MedicalCondition

Medicine allergies / allergic reaction / diabetes / /

MedicalTreatment

Radiation therapy / dialysis / Chemotherapy / /

Position

Physician / /

Product

Cialis / Viagra / Levitra / /

ProvinceOrState

Texas / /

Technology

Radiation / Chemotherapy / dialysis / /

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