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Telemedicine Informed Template 2 -Form Fill
Section One
Q1
Please check as you understand each item in this consent form*
Q2
Representative
Q3
Name of Patient
First Name
Q4
Name of Patient
Last Name
Q5
Email of Patient
Q6
Phone Number of Patient
Phone Number
Q7
Mobile Number of Patient
Phone Number
Q8
Signature of Patient
Q9
Date Signed
Date
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