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I confirm that all information given in this form is true, complete, and accurate.
- I have been explained that this Medical Provider does not accept Health Insurance.
- I have been explained that I am under no obligation to see this Medical Provider, and I can go to any Medical Provider I want.
- The first office visit does not require any money out of pocket.
- I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
