Disclosure - or payment is required and none will be...

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M. Joel Scheinbaum, MD 642 oxford Ave. Venice, CA 90291 Tel: (310) 266-5545 Fax: (310) 306-4036 Psychiatry DISCLOSURE OF PSYCHIATRIC EVALUATION Date: ______________________ Full Name: _____________________________ Address: _____________________________ Social Security Number: __________________ Date of Birth: ___________________________ The purpose of this medical visit is for evaluation only. No medication will be given or prescribed under any circumstances. No money
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Unformatted text preview: or payment is required and none will be accepted. I have read and understood the above: Signature: ___________________________ Date: _______________________ With your permission, I would like to be able to tape-record parts or all of our conversation and meeting. This is purely and totally for professional reasons. This is entirely confidential. Accept. Signature: ___________________________ Decline. Signature: ___________________________...
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