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Molly Rutherfords office is located at 1234 Franklin Road, S

Molly Rutherfords office is located at 1234 Franklin Road, S-2026

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The document is a patient information packet from Jefferson Surgical Clinic, detailing appointment procedures, required forms, and privacy policies. It includes directions to the clinic, instructions for completing necessary paperwork before appointments, and guidelines for bringing identification and insurance information. Additionally, it outlines patient rights regarding health information privacy and consent for treatment.

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Click ‘Get Form’ to open the document in the editor.
Begin by filling out the 'Patient Information' section. Enter your name, address, and contact details accurately.
Complete the 'Acknowledgement of Receipt of Privacy Notice/Consent' section by signing and dating it. Ensure you understand your rights regarding privacy.
In the 'Consent and Authorization' section, read through each point carefully before providing your signature to consent to treatment and other authorizations.
Fill out the 'Request for Release of Medical Records' if applicable, specifying which records you need released and from which facility.
Complete the 'Patient Medical History' form thoroughly, detailing any current medications, allergies, and medical conditions.
Review all sections for accuracy before saving your completed forms. You can easily export or print them directly from our platform.

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