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Patients will receive their allergy injections in our office and while the responsible physician or delegate is on the premises. Name of Supervising Physician PRINT Signature of Supervising Physician NAME OF ALLERGY FACILITY The Allergy Station FACILITY ADDRESS 1478 Eureka Road Suite 290 Roseville CA 95661 FACILITY PHONE NUMBER 916 238. Miller MD Signature of Patient Date By signing this form the supervising physician acknowledges his or her medical responsibilities. These responsibilities incl ...

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