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The document is a patient information form for Goldman Dermatology, PLLC, which collects personal details such as the patient's name, contact information, insurance details, and emergency contacts. It includes sections for primary and secondary insurance information, consent for communication regarding medical results, and authorization for treatment and payment. The form also emphasizes the importance of patient privacy.

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Versions	Form popularity	Fillable & printable
2018	4.7 Satisfied (27 Votes)

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