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Your Name
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With Whom
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With
whom did you have the experience
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Entity Name
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Name of the doctor or
hospital
or Insurance or other
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City
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State
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Zip
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If known
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Kind of
Experience
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Great, poor, problem
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Date of
Encounter
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First or last date
or about when
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Location
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Office, hospital,
mail or phone only
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Specialty
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If doctor
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Tell us
about your Experience
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Your Email
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If you want a copy of
your experience
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