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Sample Telemedicine -Form Fill
Section One
Q1
Patient Name
First Name
Q2
Patient Name
Last Name
Q3
Date of Birth
Date
Q4
Name if signed by other than the patient
First Name
Q5
Name if signed by other than the patient
Last Name
Q6
Relationship to the patient
Q7
Date
Date
Q8
Signature
Q9
Witness Name
First Name
Q10
Witness Name
Last Name
Q11
Witness Signature
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