Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MD Marco E. Bosquez, MD S. Brent Brotzman, MD Jeffrey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD Michael E. Putney, MD Stephen Rose, MD Mustasim N. Rumi, MD Michael S. Valastro, MD Steve C. Wilson, MD 16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498 12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-0000 1401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480 • • • • • • • • • • • • • •
Transcript
Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD
Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD
Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD
16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498
12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480
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•••••••
Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD
Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD
Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD
16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498
12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480
Patient Signature Date
Print Name
Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD
Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD
Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD
16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498
12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480
Pre-Op Clearance Information
Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD
Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD
Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD
16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498
12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480
