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/23/2006 Cell Phone: Name of Requesting Physician: Physician Signature: Date of Request: Office Address: Office Phone: Insurance: Yes FAX: No E-mail: If yes, attach copy of both sides of Insurance card with fax request form. If no, patient will be scheduled pending financial counseling. To be completed by the Gastroenterologist Day Hospital Reservation Liver Biopsy Indication: Chronic Hepatitis C Not needed Reserve Day Hospital bed for sameday of Procedure Abnormal Liver Function test.

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