div class=ts-pagebutton class=gotoPage data-page=1Page 1button div class=ts-imageimg data-url=media-s-name-printec-and-legible-and-phone-number-physicians-signature-datehtmlpage=1 data-page=1 class=ts-thumb lazyload alt=Page 1: media50belowcommedia50belowcomorganizations3afeeae8-5b36-4f6d-b3e7-c00e250e · Physicians Name printec and legible and phone number Physicians Signature Date stamped loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader038vdocumentinreader038viewer20221005145a7888207f8b9a7b698c60bfhtml5thumbnails1jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=2Page 2button div class=ts-imageimg data-url=media-s-name-printec-and-legible-and-phone-number-physicians-signature-datehtmlpage=2 data-page=2 class=ts-thumb lazyload alt=Page 2: media50belowcommedia50belowcomorganizations3afeeae8-5b36-4f6d-b3e7-c00e250e · Physicians Name printec and legible and phone number Physicians Signature Date stamped loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader038vdocumentinreader038viewer20221005145a7888207f8b9a7b698c60bfhtml5thumbnails2jpg width=140 height=200 divdiv