MEDICAL/ DENTAL APPOINTMEN?
(THIS FORM 1S AFFECTED BYTHE PRIVACY ACTOF 1974. USE BLANKET PAS - DD FORM 2005.)
1.
2.
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“INSTRUCTIONS
Please meet the appointment(s) made for you promptly.
Bring this slip with you and giveit to the appointmentclerk.
If you are unable to keep this appointment, cancel it at least 24 hours in advance.
IDENTIFICATION a
TYPED NAME OF PATIENT {Last - First - Middlectrmigl)
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ORGANIZATION OR HOME ADDRESS (Inchide Zip “Our. GOff
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DATE
CLINIC
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DOCTOR
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REMARKS.”
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PRIVACY ACT MATERIAL REMOVED ©
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