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Get Florida Pain Management Clinic Form

T) STATE OF FLORIDA: COUNTY OF : I certify that the foregoing instrument was acknowledged before me this day of by . He/she is personally known to me or has produced as identification and did/did not take an oath. Witness my hand and official seal in the county and state stated above on the day of ,in the year . Signature of Notary Public Notary Public for the S.

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