DATE / / HEALTH QUESTIONNAIRE - Miami Valley Plastic Surgeons
SURGERY (Previous) DATE DATE / / Frank V. Troha, M.D. • Thaddeus P. O’Neill, M.D. • Nichole Gill, PA-C 1520 S. Main Street • Suite 200 • Dayton, OH 45409 ... Medicare, private insurance, and any other health plan to: MIAMI VALLEY PLASTIC SURGEONS, INC. This assignment will remain in effect until revoked by me in writing. A photocopy ... ................
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