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Our interest in our Seating Service. Please note the following: 1. Please ensure that this form is completely filled out. This information determines if we direct your referral to a custom or commercial clinic, and helps us to prearrange equipment if appropriate. (see reverse for "Helpful Hints") 2. If there is additional information that the form does not capture, please add a note to the form. 3. If you are under 18 years of age and have not been seen at the Glenrose for any other interventi.

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