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EDC Vaginal C-Section Lab/Pathology Radiology/ Imaging Therapy: Indicate # of visits Physical Cardiac Rehab Speech Occupational Visits/Week Clinical information attached: Y / N PHYSICIAN SIGNATURE- # of pages The information contained in this form is privileged and confidential and is only for the use of the individual or entities named on this form

Complex medical histories: Individuals with significant medical conditions, multiple concurrent medications, or health factors that require hands-on clinical monitoring may benefit from in-person medical supervision rather than a telehealth-based model