Verification Of Appointment And Treatment

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Verification of Appointment and/or Procedure
Date:
This is to certify that
had/has an appointment for a
procedure/consultation on
at
.
He/She is required to adhere to the following instruction before/after the abovementioned
procedure/consultation:
Please excuse his/her lack of participation in activities that impair his/her ability to adhere to the
prescribed instructions.
Doctor’s
Signature:
Name and
Address:

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