|
Dear
Dr. _______________________,
This
states you were referred to me by one of the above websites.
Signed
________________________ Date _______________________
Patient
Information
(needed to verify with doctor and to send gift, we do NOT share
this info):
| Name
|
_____________________________________ |
|
Address
|
_____________________________________ |
| City,
State, Zip |
_____________________________________ |
| Email |
_____________________________________ |
| Phone |
_____________________________________ |
Doctor's
Signature ________________________
Fax
to 803-732-5578
or mail to: TopSurgeonsOnline, 1557 Wonder Drive, Chapin, SC
29036
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