ࡱ > ) bjbj 6 B ~ ~ Y Y Y D \ y < < * d " " " ; ; ; ; ; ; ; $ > oA n < Q Y p) ! N " p) p) < } ]< , , , p) l Y ; , p) ; , , &: | - , ; ~X .* v : ; s< 0 < : A * A $ ; A Y ; 4 " $ b , 6& R' " " " < < + " " " < p) p) p) p) A " " " " " " " " " ~ : Personal Information
In order to be seen at our facility all information must be filled out completely!Todays Date: - -
Patients Name: Last First M.I.Patients Mailing Address:StreetCity State ZipPatients Home #: - -Patients Cell / Pager #: - -
P a t i e n t s S o c i a l S e c u r i t y # : - - P a t i e n t s D O B : - -
P a t i e n t s S e x :
%
M a l e
%
F e m a l e
P a t i e n t s A g e :
P a t i e n t s M a r i t a l S t a t u s : % M a r r i e d % S i n g l e % D i v o r c e d % W i d o w e d
P a t i e n t s E - M a i l A d d r e s s : @ Y o u r e - m a i l i s important to us, because we can send you information on updates, appointments, discounts and is only used by Cosmetic Laser Center
Patients Employer:Work Phone #:
- - Extension:Spouses Name:Spouses Employer:Spouses Work Phone #:- -We will not perform treatment on anyone unless we have an emergency contact.Emergency Contacts Name:Emergency Contacts Relationship to Patient:Emergency Contacts Phone #:1) - -2) - -
Primary Care Physicians Name:If you are currently under the care of a physician, please explain.
Please indicate by numbering 1st, 2nd, 3rd, & 4th how you would like us to contact you in regards to your appointment.
HomeCellWorkE-mail
Medical History (Pg 1)
Patients Name:
Do you have any medical allergies? % Y % N I f y e s , p l e a s e l i s t b e l o w : ( e x a m p l e s : a s p i r i n , p e n i c i l l i n , s u l f a , c o d e i n e , a n t i b i o t i c s , s e d a t i v e s , l o c a l a n e s t h e t i c s , s t i m u l a n t s , D e m e r o l , d i e t p i l l s , a n t a c i d s , l a x a t i v e s , c o l d t a b l e t s , a n t i b i o t i c o i n t m e n t s , t a p e , l a t e x , t a l c p o w d e r , c o n t a c t d e r m a titis, etc.)
Allergy:Reaction:
Current Medications/Vitamins/Herbs:
List all medications and supplements you are currently taking. (Oral-Topical-Injection. Include birth control pills & non-prescription medications or vitamins)
MedicationHow ManyHow Often
List any surgeries/hospitalizations youve had:
Surgery/hospitalizationDateComplications
Have you ever had problems with general/local/regional anesthesia?YNHave you taken Zovirax, Famavir, Valtrex, or Hormone Supplements?YNDo you use tobacco products?
If yes, how many per day?YNHave you ever taken Accutane?
If yes, stop date:YNHave you ever been tested for HIV?
If yes, date of last test.YNHave you tested positive for HIV?YN
Do you or have you ever had any of the following illness or ailments? (Please circle Y or N)Column 1Column 2Column 3AcneYNFever Blisters / Cold SoresYNPoikiloderma of CivattesYNAnemiaYNGenital HerpesYNPolycystic Ovary DiseaseYNArtificial JointsYNGlaucomaYNPsoriasisYNArthritis, _______________YNHay FeverYNRadiation TherapyYNAuto Immune DiseaseYNHeart Problems / DiseaseYNRecent Weight Gain/LossYNBleeding ProblemsYNHeart MurmurYNRheumatic FeverYNBlood Clots / PhlebitisYNHepatitis or Yellow JaundiceYNRosaceaYNBlood Transfusion ReactionYNHernia
Type:YNThyroid DiseaseYNBreathing / Lung ProblemsYNHigh Blood PressureYNTumors
Where?YNCancer
Where?YNHives or RashesYNSeizuresYNCardiac PacemakerYNHistory of Skin CancerYNStomach / Bowel ProblemsYNConnective Tissue DiseaseYNKeloid/Excessive ScarYNUlcersYNCurrent Infections What/Where? YNKidney Disease/ProblemsYNUltraviolet Light TherapyYNCVA (Stroke)YNLiver Disease / ProblemsYNVein TreatmentYNDiabetesYNMelasmaYN
Other:EmphysemaYNMitral Valve ProlapseYN FORMCHECKBOX Laser Hair Removal FORMCHECKBOX Permanent Cosmetics FORMCHECKBOX Skin Care (Glycolic Peel or Microdermabrasion) FORMCHECKBOX ClearLight Acne Treatment FORMCHECKBOX Photo-rejuvenation (face/neck) FORMCHECKBOX Botox, Collagen, or Restylane What is the reason for your visit today?
Please let us know how you heard about us:
If you were referred by a person; may we thank him or her? FORMCHECKBOX Yes FORMCHECKBOX NoPatients Name: Medical History (pg 2)
XPatients Signature FINANCIAL POLICY AND RESPONSIBILITY
Policy
Cosmetic Laser Center wants you to clearly understand your financial respon sibility for services rendered. After your initial evaluation, and before treatment is started, the findings and treatment recommendations will be explained to you. Additionally, the cost of such treatments will be stated.
Cosmetic Laser Center is not a provider under any HMO, PPO, MEDICARE, or other insurance program. If you have health insurance, it is your responsibility to seek reimbursement from your in surer, if desired and if available. Most procedures performed at the Cosmetic Laser Center are cos metic and will not be covered under many insurance policies. The Cosmetic Laser Center will furnish you with any available information regarding your services that you may require to file your claim.
Payment for each service performed at the Cosmetic Laser Center is due at the time the service is rendered. You may pay by cash, check, MasterCard, Visa, Discover, or Ameri can Express. If you desire to make other payment arrangements, please ask to speak to our busi ness manager before treatment is performed. Any payment plan that is approved will require you to (a) submit additional financial information and (b) pay interest and a service charge.
When you pay with a check and the check is returned to us for any reason, we will send you a letter with a copy of the returned check along with a bill for any bank fees and a returned check fee of $20. When you pay by check, you agree to this returned check policy.
Responsibility
By signing below, you agree to pay all amounts due on your account as services are rendered. Payment in full is due upon the scheduling of your first appointment, not at the time of your first treatment. All sales are final. No refunds will be issued on packages. Unused portions of packages can be transferred to other services. If for any rea son a balance is due on your account, a late charge of 5% will be added for each month you are late. All treatments will be suspended until payment is made in full. If collection efforts are required, you agree to pay costs of collection, including, attorneys fees, court costs and any other costs relating to your collection. If special payment arrangements have been made with the Cosmetic Laser Center, you agree to pay in accordance with those terms.
You hereby authorize the release of any and all information to any in surance company requesting it relating to services performed by the Cosmetic Laser Center.
We know your time is valuable, as ours and other patients. If you cancel or reschedule your appointment within 24 hours of your appointment you may be subject to an additional fee of $50.00. You are also subject to this fee if you no show for your appointment without canceling.
XResponsible PartyDate
Your Rights and
Responsibilities as a PATIENT at Cosmetic Laser Center
I have received the Notice of privacy practices and i have been provided an opportunity to review it.
Acknowledgement form
Name:
Birth date:
Signature:
Todays Date:Whom, if any, can we discuss your medical treatment with: (please list)
Your Rights and Responsibilities as a PATIENT at Cosmetic Laser Center
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!
This notice takes effect 9/1/03 and remains in effect until we replace it, at that time you will be notified in writing of any changes.
1. Our Pledge regarding medical informationThe privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care & services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.
2. OUR LEGAL DUTYLaw Requires Us to:
Keep your medical information private.
Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
Follow the terms of the current notice.
We Have the Right to:
Change our privacy practices and terms of this notice at any time; provided the law permits the changes.
Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including previously created or received before the changes.
Notice of Change to Privacy Practices:
Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
3. Use and disclosure of your medical informationThe following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will NOT use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address at the end of this notice.
For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them or us in treating you.
For Payment: WE may use and disclose your medical information for payment purposes. A bill/receipts may be given/sent to you. The information on or accompanying the bill may include your medical information.
For Health Care Operations: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.
ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medial information for treatment, payment, and health care operations, me may use and disclose medical information for the following purposes.
Facility Directory: The following medical information about you will be placed in our computer database: your name, address, phone number, birth date, e-mail address, your condition described in general terms, allergies, pertinent medical condition, and how you heard about our facility.
Notification: We may use and disclose medical information in case of emergency to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location or general condition. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment.
Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing our controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration (FDA) for purposes of reporting adverse events associated with product defects or problems to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the FDA. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contacting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose medical information for purposes of reminding you of your appointments.
Alternative and Additional Medical Services: We may use and disclose medical information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.
4. Your individual rightsYou Have a Right to:
Look at or get copies of certain pages of your medical information. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, we will charge you $.20 for each page, and postage if you want the copies mailed to you.
Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency)
Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.
Contact Information
Larry Branam, RN, Owner
7030 Mexico Road, Suite A
636-397-4002
www.cosmeticlasercenter.org ~ e-mail: info@cosmeticlasercenter.org
Cosmetic Laser Center
Cosmetic Laser Center
Women OnlyDate last menstrual period started: i w $ % & ' . / 0 1 2 3
<
f
V Z j l n | ~ X *h] h 6CJ aJ h 5\ h 6CJ ] h 6CJ ]
h CJ h 5CJ \ h 56@( CJ \h h 5:E i w Y M $$If a$gd kd $$If l F r $ 0 6 4
l a $If gd $$If a$gd $a$gd $a$gd s kd $$If l 0 $ ( @ 0 6 4
l a $$If a$gd $ % w $$If a$gd $If gd s kd $$If l 0 p$ 0 6 4
l a % & ' . ~ ~ $$If a$gd u kdY $$If l 0 @ $ 0 6 4
l a . / 0 1 $$If a$gd s kd $$If l 0
$ R 0 6 4
l a 1 2 3 $$If a$gd s kd $$If l 0
$ R 0 6 4
l a $$If a$gd s kd $$If l 0
$ R 0 6 4
l a w $If gd $$If a$gd s kdY $$If l 0 p$ 0 6 4
l a
<
d
f
S K ? ? ? ? ? $$If a$gd $a$gd kd $$If l r $ (
0 6 4
l a
S G G G G G G G $$If a$gd kdC $$If l r @ $ p $ 0 6 4
l a
$$If a$gd " V Z . % % % $If gd kd $$If l iZr $ e 9 ) ( 6 $ $ $ $ 4
l a Z j n | $If gd . & $If gd $a$gd kd $$If l @
6$ v 6 $ $ $ $ 4
l a ~ v v j j $$If a$gd $a$gd u kd
$$If l p0 $ P 0 6 4
l a $$If a$gd X
*
,
C
W
X
Z
T V u w : ; T U e i o p ȷȷȷȷȰ h 6:CJ aJ h 5:CJ aJ h 5:aJ h 5 h \
h 5CJ
h CJ H*h CJ OJ QJ
h CJ h 6CJ ] h 6CJ ] h h 5CJ \
h 6CJ *h] h 6CJ 2
$If gd s kd_ $$If l 0 % % G 0 l%6 4
l a
u $$If a$gd $If gd u kd $$If l ^0 %
_ 0 l%6 4
l a
*
+
$If gd u kd $$If l g0 % r 0 l%6 4
l a +
,
C
V
p $
! $If a$gd $If gd u kd
$$If l 0 ~ % 0 l%6 4
l a V
W
X
Y
u $$If a$gd $If gd u kd] $$If l 0 @ C i 0 l%6 4
l a Y
Z
~ r $$If a$gd $$If a$gd u kd& $$If l 0 $ % |$ 0 l%6 4
l a
u $$If a$gd $If gd u kd $$If l 0 $ % |$ 0 l%6 4
l a
u $$If a$gd $If gd u kd $$If l 0 % w 0 l%6 4
l a
1 T $If gd u kdI $$If l 0 ! % 0 l%6 4
l a T U V u v $$If a$gd $a$gd a kd $$If l F ;
A %
l%6 4
l a v w $$If a$gd n kd $$If l 0 $ | 0 6 4
l a $$If a$gd n kdS $$If l 0 $ b 0 6 4
l a : ; @ A F G L M T v c v c v c v c $
d $If a$ gd $
d $If a$gd $a$gd n kd $$If l 0 $ b 0 6 4
l a T U V p q F > > 2 $$If a$gd $a$gd kd $$If l ִ = H $ , > t 6 4
l a p q
H
1 U Z ] n 9 = [ \ v z ! " # * r 誠 h 5;\h 5;CJ \h 5;CJ \ j h CJ UmH nH u h 6CJ ] h 6CJ OJ QJ ] h OJ QJ
h CJ h h 5CJ \ h 5@( CJ$ \:q q i i ] $$If a$gd $a$gd kd $$If l F $ J 2 0 4
l a $If gd
{ t f Z $$If a$gd $x $If a$gd x gd kd $$If l r
xL
h h 4
l a ! " # | $$If a$gd $If gd n kdf $$If l 0 L ~ 0 6 4
l a # $ % & $If gd n kd $$If l 0 L ~ 0 6 4
l a & ' ( ) $If gd p kd $$If l 0 L ~ 0 6 4
l a ) * + , $If gd p kdu $$If l 0 L ~ 0 6 4
l a , - . / $If gd p kd* $$If l 0 L ~ 0 6 4
l a / 0 1 U ~ ~ ~ $$If a$gd gd p kd $$If l 0 L ~ 0 6 4
l a ~ u u u $If gd kd $$If l F o L 0 6 4
l a ~ u u u $If gd kdE $$If l F o L 0 6 4
l a ! | s s s $If gd kd $$If l F o L 0 6 4
l a ! " # $ % | s s s $If gd kd $$If l F o L 0 6 4
l a % & ' ( ) | s s s $If gd kd $$If l F o L 0 6 4
l a ) * + , - | s s s $If gd kdM $$If l F o L 0 6 4
l a - . / 0 1 | s s s $If gd kd $$If l F o L 0 6 4
l a 1 2 3 4 5 | s s s $If gd kd $$If l F o L 0 6 4
l a 5 6 7 8 9 : ; < = > n | s s s s s s s s s f
$If ]gd ]gd kd! $$If l F o L 0 6 4
l a q kdY" $$If l F s ^ G0 6 4
l a
$If ]gd ~ q q q
$If ]gd kd# $$If l F s ^ G 0 6 4
l a | o o o
$If ]gd kd# $$If l F s ^ G 0 6 4
l a | o o o
$If ]gd kd$ $$If l F s ^ G 0 6 4
l a | o o o
$If ]gd kdo% $$If l F s ^ G 0 6 4
l a | o o o o
$If ]gd kd:& $$If l F s ^ G 0 6 4
l a 9 ; = | o o o
$If ]gd kd' $$If l zF
9 7 0 6 4
l a = > [ v x z | o o o o
$If ]gd kd' $$If l vF
970 6 4
l a z { | o o o o
$If ]gd kd( $$If l F
970 6 4
l a | o o o o
$If ]gd kd\) $$If l vF
970 6 4
l a | o o o
$If ]gd kd * $$If l F
970 6 4
l a | o o o
$If ]gd kd* $$If l F
9 70 6 4
l a ! # $ % & ' ( ) * | s k k k k k k k $a$gd ]gd kd+ $$If l MF
970 6 4
l a * f f f f f M $$X&`#$/ If ]a$gd $$X&`#$/ If ]a$gd i kdn, $$If l ," "
6`X 0 6 4
l a $X&`#$/ If ]gd Ffo3 $$X&`#$/ If ]a$gd $X&`#$/ If ]gd Ff. $$X&`#$/ If ]a$gd + / 0 B F O S ] a b }
/ 3 4 L P m q y } ~
! 1 5 > B C U Y p t j h CJ UmH nH u h h 5CJ \
h CJ W + - / 0 B D F O Q S ] _ a b } Ff< $$X&`#$/ If ]a$gd Ff7 $X&`#$/ If ]gd
/ 1 3 4 L FfJ FfE $$X&`#$/ If ]a$gd $X&`#$/ If ]gd FfA L N P m o q y { } ~ Ff'S FfN $$X&`#$/ If ]a$gd $X&`#$/ If ]gd
! 1 3 5 > @ B C U W Y p FfO\ FfW $$X&`#$/ If ]a$gd $X&`#$/ If ]gd p r t 1 Ffwe Ff` $$X&`#$/ If ]a$gd $X&`#$/ If ]gd 1 5 6 C G ` d s w x $ % & ' V W e f g h je| h CJ Uj{ h CJ Ujz h CJ U
h CJ \jbz h CJ Uj h CJ U j h CJ UmH nH u h h 5CJ \
h CJ :1 3 5 6 C E G ` b d s u w x Ffn $$X&`#$/ If ]a$gd Ff
j $X&`#$/ If ]gd $+&`#$/ If gdNYO Ffw $$X&`#$/ If ]a$gd $X&`#$/ If ]gd Ff9s ' V h s s s s $+&`#$/ If gdNYO { kdJ{ $$If l D\ r& V
6`+ '6 4
l a s s s s $+&`#$/ If gdNYO { kd| $$If l h\ r& V
6`+ '6 4
l a ? @ | } ۽۹۲ۍyunc h 6:CJ aJ h 5: hh$ hh$ 5CJ \ hh$ 5@ CJ$ \ h 5CJ OJ QJ j h CJ Uj h CJ U
h CJ \h
hNYO CJ \j} h CJ Uh 6CJ \]
h CJ \
h CJ j h CJ Uj} h CJ U # p p $$+&`#$/ If a$gdNYO { kdh~ $$If l \ r& V
6`+ '6 4
l a > ? o o o $$+&`#$/ If a$gdNYO | kd $$If l 0 Q& [
6`+ 0 '6 4
l a ? @ A | t t t t t a $ $+&`#$/ If a$ gdNYO $+&`#$/ If gdNYO z kd $$If l 0
% y
6`+ 0 '6 4
l a I 6 & & $ &`#$/ If gdh$ $$ &`#$/ If a$gdh$ kd $$If l r L@ Z & u R
6`+ 0 '6 4
l a p h P $f"&#$/ If ]b$gdh$ $a$gd kd $$If l F p& z b <
6` 0 ' 4
l a yth$ 5 M c P f b x " " " " " " " # # 7# 8# i# j# $ % xnf[f[Whq *hIm4 hq 5>* *hq 5>* *hIm4 hq >* *h
u hq 5>*h] h >*hNYO h 56 h 5h hh$ hNYO CJ aJ (j hh$ hNYO CJ UaJ mH nH u ,j hh$ hh$ CJ UaJ mH nH tHu hh$ 5CJ \ *hh$ 6CJ OJ QJ ] hh$ 5\ hh$ hh$ 5CJ \" w $f"&#$/ If ]b$gdh$ p kd} $$If l
6f" 0 6 4
l a e4yth$ L M 7 8 ! ! " w w k w b w w w
gd
d gd d gd $a$gdNYO $a$gdh$ p kd8 $$If l I
6f" 0 6 4
l a e4yth$ " " " D% E% % % ' ' ' ' ' ' ' u f kd $$If l F !," 9
6` 6 4
l a d $ &`#$/ If gdNYO d gd d gd
% D% E% % % %& ' ' ' ' !' (' 8' 9' p' q' r' s' ' ' ' ' ' ' ( ( ( ( )( +( .( 0( 3( 5( p( }( ( ( ( ( ( ( ( ɼzzzzzmzzzz h 6CJ \]wh h CJ \wh *h CJ \wh hE 6;]hE 6;CJ OJ QJ ]h ;CJ \wh h ;\wh h 5;>*CJ wh h >*CJ wh hE *hNYO h 5>*\ *hUC h 5>*\ hNYO
hNYO CJ hh *' ' !' "' #' $' %' &' '' (' 9' p' q' x x x x x x x x x k
&dP gd
&dP gdNYO f kd $$If l F L
,"
9
6` 6 4
l a d $ &`#$/ If gdNYO q' r' s' ' ' ' ' ' ' ' ' ' r r r r
! $&P#$/ If gdE V kd9 $$If l <' ' `
6`
6 4
l `
a p
$ &`#$/ If gdE
! gd $a$gd ' ' ( ( (
( ( ( ( ( ( X y kd $$If l \ 71 %
6P 6 4
l a
! $&P#$/ If gdE $
! $&P#$/ If a$gdE
( ( ( )( *( +( ,( -( .( /( X y kdy $$If l \ 71 %
6P 6 4
l a
! $&P#$/ If gdE $
! $&P#$/ If a$gdE /( 0( 1( 2( 3( 4( p p X p $
! $&P#$/ If a$gdE
! $&P#$/ If gdE y kd2 $$If l \ 71 %
6P 6 4
l a 4( 5( 6( ~( ( ( p p X p $
! $&P#$/ If a$gdE
! $&P#$/ If gdE y kd $$If l \ 71 %
6P 6 4
l a ( ( ( ( ( ( n n V n $
! $&P#$/ If a$gdE
! $&P#$/ If gdE { kd $$If l _\ E1 %
6P 6 4
l a ( ( ( ( ( ( p p X p $
! $&P#$/ If a$gdE
! $&P#$/ If gdE y kdK $$If l \ 71 %
6P 6 4
l a ( ( ( ( ( ( p p X p $
! $&P#$/ If a$gdE
! $&P#$/ If gdE y kd $$If l \ 71 %
6P 6 4
l a ( ( ( ( ( ( n n V n $
! $&P#$/ If a$gdE
! $&P#$/ If gdE { kd $$If l C\ 71 %
6P 6 4
l a ( ( ( ( ( ( ( ( ) ) ) ) ) ** -* U* V* W* t, , , , , , :- ;- ð{j{]M{]AAA hNYO hNYO 5CJ \ hNYO hNYO 6CJ OJ QJ ] hNYO hNYO 5>*CJ \!hNYO hNYO 6;CJ OJ QJ ]!hNYO hNYO 6:CJ OJ QJ ]hNYO hNYO >*CJ hNYO hNYO CJ !hNYO hNYO 5>*CJ OJ QJ \$hNYO hNYO 56CJ OJ QJ \] hNYO hNYO CJ aJ hE CJ aJ hNYO CJ aJ h CJ aJ h h CJ \wh h ;CJ \wh ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( | z z z z z z z z z z z z
# gd y kdB $$If l \ 71 %
6P 6 4
l a ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ) ) ) ** gdNYO gdNYO
&dP gdNYO ** V* W* t, , , , , ] X G
& F
h ^ gdNYO gdNYO J kde $$If l <' ' `
6 4
l `
a p
gdNYO J kd $$If l <' ' `
6 4
l `
a p
$If gdE , ;- c- y- - . . L/ ~/ / 1 1 2 3 5 5
& F gdNYO J kdݍ $$If l <' ' `
6 4
l `
a p
$If gdE
& F gdNYO
& F gdNYO gdNYO
& F gdNYO ;- b- y- - - . . K/ L/ ~/ / w0 1 1 2 3 3 3 3 5 35 5 5 7 7 k9 {9 : #: ; < $> ?> A HA ZC jC uE E E F F G G G L L L M "M #M %M &M (M )M +M ,M .M öکک h"D j h"D UhNYO hNYO CJ aJ hNYO hNYO 6;CJ ]hNYO hNYO 5;CJ \hNYO hNYO >*CJ hNYO hNYO 6:CJ ]!hNYO hNYO 6;CJ OJ QJ ]hNYO hNYO 5CJ \ hNYO hNYO CJ 95 7 k9 : ; $> A ZC uE E F G G G H I
& F gdNYO gdNYO J kdU $$If l <' ' `
6 4
l `
a p
$If gdE
& F
0`0gdNYO
& F gdNYO I J K L L L L L L L M !M "M $M %M 'M (M *M +M gdNYO J kd͎ $$If l <' ' `
6 4
l `
a p
$If gdE
& F gdNYO +M -M .M zM {M M M M M M M
$If ]
&d P
.M /M 7M 8M =M >M PM yM {M |M M M M M M M M M M M ( ( ( ( <) =) >) ) ) ) ) ) ⯦ hh$ hh$ hh$ CJ
hh$ CJ hNYO hNYO CJ aJ hNYO h CJ aJ U
h CJ h 5B*\ph h"D h h 5: h 5:]h 5:CJ( ] M M M M M Z P P P
$If ] kdE $$If l F ,8$ YYY YYY YYY 0 4
l a p YYY YYY YYY M M G( I( K( } s s s
$If ] kd $$If l _F
8$ n
6 0 4
l a Any problems with your menstrual period/cycle? If yes, please explain:YNContraception Method:Any chance you are pregnant?YNAre you currently breastfeeding?YNOB/GYN Physician:
Other than what you are coming in for today, are you interested in any other services? (Please check all that apply)
I acknowledge that I have answered all of the above questions truthfully and completely to the best of my knowledge and recollection.
K( L( M( N( O( } s s s
$If ] kd $$If l F x$ h D 0 4
l a O( P( f( g( h( u u u
$If ] kd $$If l F 8$ " 0 4
l a h( i( ( ( ( } s s s
$If ] kdx $$If l F ~ $ v 0 0 4
l a ( ( ( ( ( } s s s
$If ] kdp $$If l F x$ h D 0 4
l a ( ( ( ( ( } s s s
$If ] kdh $$If l F x$ h D 0 4
l a ( ( ( ( =) >) ) ) ) ) } x v v v v v v v gd kd` $$If l 2 F 8$ " 0 4
l a 2 &P :p / =!"#$h% 3 0 &P / =!"#$% P / 0 &P / =!"#$% 2 1h:pE / =!"#$% $$If !v h5 55#v #v#v:V l 0 6 ,5 55/ / / 4 $$If !v h5 (5@ #v (#v@ :V l 0 6 5 (5@ / / / 4 $$If !v h5 5 #v #v :V l 0 6 5 5 / / / 4 $$If !v h5 5#v #v:V l 0 6 5 5/ / / 4 $$If !v h5 R 5#v R #v:V l 0 6 5 R 5/ / / 4 $$If !v h5 R 5#v R #v:V l 0 6 5 R 5/ / / 4 $$If !v h5 R 5#v R #v:V l 0 6 5 R 5/ / / 4 $$If !v h5 5 #v #v :V l 0 6 5 5 / 4 E$$If !v h5 (555
5#v (#v#v#v
#v:V l 0 6 5 (555
5/ / / / / / / / 4 E$$If !v h5 5p555$ #v #vp#v#v#v$ :V l 0 6 5 5p555$ / / / / / / / / 4 $$If !v h5 e55555595)5 (#v e#v#v#v#v#v#v9#v)#v (:V l 6 5 e55555595)5 (/ 4 $$If !v h5 55555v55 5 #v #v#v#v#v#vv#v#v #v :V l 6 , 5 55555v55 5 4 $$If !v h5 5P#v #vP:V l p0 6 ,5 5P/ / / 4 $$If !v h5 % 5G #v % #vG :V l 0 l%6 5 % 5G / / / 4 $$If !v h5
5_ #v
#v_ :V l ^0 l%6 , 5
5_ / 4 $$If !v h5 r5 #v r#v :V l g0 l%6 , 5 r5 / / /
4 $$If !v h5 5#v #v:V l 0 l%6 , 5 5/ / /
4 $$If !v h5 C 5i#v C #vi:V l 0 l%6, 5 C 5i/ / / 4 $$If !v h5 |$5 #v |$#v :V l 0 l%6 , 5 |$5 / 4 $$If !v h5 |$5 #v |$#v :V l 0 l%6 , 5 |$5 / 4 $$If !v h5 5w#v #vw:V l 0 l%6 , 5 5w/ / / 4 $$If !v h5 5#v #v:V l 0 l%6 , 5 5/ / /
4 $$If !v h5
5 5 #v
#v #v :V l l%6 , 5
5 5 / 4 $$If !v h5 |5#v |#v:V l 0 6 5 |5/ / 4 $$If !v h5 b5 #v b#v :V l 0 6 5 b5 / /
/ 4 $$If !v h5 b5 #v b#v :V l 0 6 5 b5 / / 4 $$If !v h5 555555i5#v #v#v#v#v#v#vi#v:V l 6 5 5,5555>55t/ / / / 4 $$If !v h5 5J52 #v #vJ#v2 :V l 0 ,5 5J52 / / / 4 $$If !v h5
5h5 5h5#v
#vh#v #vh#v:V l , ,5
5h5 5h54 $$If !v h5 5- #v #v- :V l 0 6 , 5 5~ / 4 $$If !v h5 5- #v #v- :V l 0 6 5 5~ / / 4 $$If !v h5 5- #v #v- :V l 0 6 5 5~ / /
4 $$If !v h5 5- #v #v- :V l 0 6 5 5~ / /
4 $$If !v h5 5- #v #v- :V l 0 6 5 5~ / /
4 $$If !v h5 5- #v #v- :V l 0 6 5 5~ / /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ 4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ / 4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 557#v #v#v7:V l 0 6 5 5/ /
4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ 4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ / 4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ /
4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ /
4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ /
4 $$If !v h5 5^5G#v #v^#vG:V l 0 6 5 5^5G/ /
4 $$If !v h5 9557#v 9#v#v7:V l z0 6 ,5 9557/ / 4 $$If !v h5 9557#v 9#v#v7:V l v0 6 ,5 9557/ 4 $$If !v h5 9557#v 9#v#v7:V l 0 6 ,5 9557/ 4 $$If !v h5 9557#v 9#v#v7:V l v0 6 ,5 9557/ 4 $$If !v h5 9557#v 9#v#v7:V l 0 6 , ,5 9557/ 4 $$If !v h5 9557#v 9#v#v7:V l 0 6 5 9557/ 4 $$If !v h5 9557#v 9#v#v7:V l M0 6 , ,5 9557/ 4 $$If !v h5 "#v ":V l
6`X 0 6 5 "/ 4 $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l g
6`X < 0 6 , 5 5P55P5D 5 P/ / / / 4 p< kd- $$If l g T
H ," P P P P D P P
6`X < 0 6 $ $ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l (
6`X < 0 6 , 5 5P55P5D 5 P/ / / / 4 p< kd1 $$If l ( T
H ," P P P P D P P
6`X < 0 6 $ $ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kd6 $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kd: $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kd? $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kdC $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kd"H $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l D
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kdL $$If l D T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l h
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / 4 p< kd2Q $$If l h T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l V
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kdU $$If l V T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kdPZ $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l ;
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kd^ $$If l ; T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l h
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kdtc $$If l h T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l .
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kd
h $$If l . T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kdl $$If l T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l D
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kd6q $$If l D T
H ," PPPPD PP
6`X < 0 6 $$ $ $ 4
l a p< $$If !v h5 5P5P55P5P5D 5P5 P#v #vP#v#vP#vD #v P:V l
6`X < 0 6 , 5 5P55P5D 5 P/ / / / / / 4 p< kdu $$If l T
H ," P P P P D P P
6`X < 0 6 $$ $ $ 4
l a p< t D e C h e c k 1 t D e C h e c k 1 $$If !v h5 5V5 5 #v #vV#v #v :V l D
6`+ '6 , 5 5V5 5 4 t D e C h e c k 1 t D e C h e c k 1 $$If !v h5 5V5 5 #v #vV#v #v :V l h
6`+ '6 , 5 5V5 5 4 t D e C h e c k 1 t D e C h e c k 1 $$If !v h5 5V5 5 #v #vV#v #v :V l
6`+ '6 , 5 5V5 5 4 $$If !v h5 5[#v #v[:V l
6`+ 0 '6 5 5[/ / / 4 $$If !v h5 y5#v y#v:V l
6`+ 0 '6 5 y5/ / / 4 h D e v D e C h e c k 3 1 $$If !v h5 5u555R#v #vu#v#v#vR:V l
6`+ 0 '6 , 5 5u555R/ 4 $$If !v h5 z5b5< #v z#vb#v< :V l
6` 0 ' ,5 z5b5< / / / 4 yth$ $$If !v h5 #v :V l
6f" 0 6 5 / / 4 e4yth$ $$If !v h5 #v :V l I
6f" 0 6 5 / / 4 e4yth$ $$If !v h5 559#v #v#v9:V l
6` 6 5 559/ / 4 $$If !v h5
5 59#v
#v #v9:V l
6` 6 5
5 59/ / 4 $$If !v h5 '#v ':V l `
6`
6 5 '4 `
p
$$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / / 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / / 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / / 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / / 4 $$If !v h5 55 5 #v #v#v #v :V l _
6P 6 ,5 55 5 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / 4 $$If !v h5 555 #v #v#v#v :V l C
6P 6 5 555 / 4 $$If !v h5 555 #v #v#v#v :V l
6P 6 5 555 / 4 v $$If !v h5 '#v ':V l `
6 5 '4 `
p
v $$If !v h5 '#v ':V l `
6 5 '4 `
p
v $$If !v h5 '#v ':V l `
6 5 '4 `
p
v $$If !v h5 '#v ':V l `
6 5 '4 `
p
v $$If !v h5 '#v ':V l `
6 5 '4 `
p
S$$If !v h5 5 5 #v #v #v :V l YYY YYY YYY 0 5 5 5 / / / / / / / 4 p YYY YYY YYY $$If !v h5 n
565 #v n
#v6#v :V l _0 , 5 n
565 / / / / / 4 $$If !v h5 5h5D#v #vh#vD:V l 0 , 5 5h5D/ / / / / 4 $$If !v h5 5" 5 #v #v" #v :V l 0 5 5" 5 / / / / / 4 $$If !v h5 5v50#v #vv#v0:V l 0 , 5 5v50/ / / / / 4 $$If !v h5 5h5D#v #vh#vD:V l 0 , 5 5h5D/ / / / / 4 $$If !v h5 5h5D#v #vh#vD:V l 0 , 5 5h5D/ / / / / 4 $$If !v h5 5" 5 #v #v" #v :V l 2 0 , 5 5" 5 / / / / / 4 ^ 2 0 @ P ` p 2 ( 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 0 @ P ` p 8 X V ~ _HmH nH sH tH < ` < N o r m a l CJ _HmH sH tH @ @ @ H e a d i n g 1 $@& CJ( OJ QJ F @ F H e a d i n g 3 $@& 6CJ OJ QJ ] L @ L H e a d i n g 5 $$@&a$ 5CJ OJ QJ \ D A` D D e f a u l t P a r a g r a p h F o n t R i@ R T a b l e N o r m a l 4
l 4 a ( k ( N o L i s t 4 @ 4 H e a d e r
! : B@ : B o d y T e x t CJ OJ QJ 2 O 2 t 1 d 1$ CJ h 8 O "8 c 6 $d 1$ a$ CJ h : O 2: p 7
d! 1$ CJ h : O B: p 8
d7 1$ CJ h @ P@ R@ B o d y T e x t 2 $a$ 5CJ H bH h$ B a l l o o n T e x t CJ OJ QJ ^J aJ N / qN h$ B a l l o o n T e x t C h a r CJ OJ QJ ^J aJ PK ! [Content_Types].xmlj0Eжr(Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi} ;~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭? PK ! ֧ 6 _rels/.relsj0 }Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_ 6LR7`0̞O,En7Lib/Se е PK ! ky theme/theme/themeManager.xml M
@}w7c(Ebˮ CAǠҟ7՛K
Y,
e.|,H ,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8 PK ! P theme/theme/theme1.xmlYOo6w toc'vuر-Mn iP@I}úama[إ4:l ЯGRX^6؊>$ !)O^rC$y@ /yH*)UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSe bORD۫qu gZo~ٺlAplxpT0+[}`j zA V2Fi@qv֬5\|ʜ̭NleXd sjcs7f
W+Ն7` g ȘJj|h(KD-
dXiJ؇(x$( :;˹! I_TS 1?E ??ZBΪmU/ ?~xY'y5g&/ɋ>GMGeD3Vq%'#q$8K )fw 9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD 1NIBs
RuK>V.E L+M2#'fi ~V vl{u8z H
* :( W ☕
~JTe\O*tHGHY }KNP*ݾ˦ TѼ9/#A7qZ $*c?qUnwN%Oi4 =3ڗP
1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g-
eW
)6-rC Sj
id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q% p%m&]caS l=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f
Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ .uχYC6OMf3or$5N HT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R 3U~7+#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vp IYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07% < ҍ PK !
ѐ ' theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э5
6?$Q
,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/ ]QAsم(#L[ PK- ! [Content_Types].xmlPK- ! ֧ 6 + _rels/.relsPK- ! ky theme/theme/themeManager.xmlPK- ! P theme/theme/theme1.xmlPK- !
ѐ ' theme/theme/_rels/themeManager.xml.relsPK ]
s tE s
tE 6 46 i6 6 Y Y Y Y Y Y Y Y Y Y Y Y X p % ( ;- .M ) ' 7 F g m r x | % . 1
Z
+
V
Y
T v T q # & ) , / ! % ) - 1 5 = z * L p 1 ? " ' q' ' ( /( 4( ( ( ( ( ( ( ** , 5 I +M M M K( O( h( ( ( ( ) ( ) * + , - . / 0 1 2 3 4 5 6 8 9 : ; < = > ? @ A B C D E G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f h i j k l n o p q s t u v w y z { } ~ x 2 B c s + ; A Q tE G$G$G$G$G$G$G$G$ 8 @ 4 (
B
jJ ? # " ?
z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? z B
6
D ? # " ? t
3 S " ? ?
t
# c "$ ?
B
S ?
H
S
A tE
4
# 4
4 y u | 4 4 [ 4 m
4 r 4 b j 4 Q '$ " t $ ! ' t # 6
5 T 6
5 ,
6
5 6
5 | 6
5 d 6
5 6
5 tu 6
5 u 6
5 6
5 Z 6
5 t 6
5 $" 6
5 6
5 _ 6
5 " 6
5 | 6
5 4 6
5 ) 6
5 6
5 6
5 6
5 \ !6
5 "6
5 #6
5 $6
5
F
_ e g o B B B B B B B B B B B B wC xC uE C [ (
) B B B B B B B B B B B B wC xC uE 3 3
x x W W q q ! ! " " Z B xC uD D D D D rE uE
x x W W q q B B B B B B B B B B B B *C *C wC xC uD uD D D D rE uE y* - y)AE D "E jOH֬ ]m֬ Hv
Δ h ^` . h ^` . h pL p^p`L . h @ @ ^@ ` . h ^` . h L ^`L . h ^` . h ^` . h PL P^P`L . h 8 8^8` . h ^` . h L ^`L . h ^ ` . h x x^x` . h HL H^H`L . h ^` . h ^` . h L ^`L . h ^` . h ^` . h pL p^p`L . h @ @ ^@ ` . h ^` . h L ^`L . h ^` . h ^` . h PL P^P`L . h ^`OJ QJ o( h ^`OJ QJ o( h p p^p`OJ QJ o( h @ @ ^@ `OJ QJ o( h ^`OJ QJ o( o h ^`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h P P^P`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h p p^p`OJ QJ o( h @ @ ^@ `OJ QJ o( h ^`OJ QJ o( o h ^`OJ QJ o( h ^`OJ QJ o( h ^`OJ QJ o( o h P P^P`OJ QJ o( h 8 8^8` . h ^` . h L ^`L . h ^ ` . h x x^x` . h HL H^H`L . h ^` . h ^` . h L ^`L . D y* Hv y)A ]m jOH &! h$ NYO q "D E B B @ @{L C tE p @ p
p @ p p $ @ p P@ U n k n o w n G * T i m e s N e w R o m a n 5 S y m b o l 3. * A r i a l G G o u d y O l d S t y l e 7N M i s t r a l 5. * a T a h o m a ; W i n g d i n g s ?= * C o u r i e r N e w A B C a m b r i a M a t h " 1 h "Ħچ $ 8 " y 8 " y ! 4 B B 2Q HX ? 2 ! x x P E R S O N A L I N F O R M A T I O N
L a r r y B r a n a m $ Oh +'0
< H
T ` h p x PERSONAL INFORMATION Normal Larry Branam 3 Microsoft Office Word @ u @ l@ \ȻX 8 ՜. +,0 h p |
y " B PERSONAL INFORMATION Title
! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~
R o o t E n t r y F X D a t a
X 1 T a b l e B W o r d D o c u m e n t 6 S u m m a r y I n f o r m a t i o n (
D o c u m e n t S u m m a r y I n f o r m a t i o n 8 C o m p O b j y
F' Microsoft Office Word 97-2003 Document
MSWordDoc Word.Document.8 9q