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    Referred to clinic by:



    INSURANCE INFORMATION

    (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST.)

    Primary Insurance
    Secondary Insurance

    IN CASE OF EMERGENCY

    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Cannabis MD or insurance company to release any information required to process my claims.