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Services in Obstetrics and Gynecology. Patient Name: Referral Source (Physician Only) DOB(M/D/Y): Name: PHN: Gender: M F PRACID: Address: Address: Tel: Tel: Alt Tel: Fax: Patient aware of referral Claim Family MD: Reason for Referral: (provide any supporting documentation) Previous History & Investigations: Medications: Please indicate any specific services you wish Dr. Taher Al-Jishi to review: General Gyne Consultation & Exam IUD Insertion / Removal Urogyne / Incontinence.

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