WOODSON C. MERRELL, M.D.
Telephone:
Fax:
Checklist for New Patient Inquiries
Date: 10/10/11
Taken By:
Name:
Age: 32
DOB:
Address:
Phone:
SS#:
Email:
Referred by: Jeffrey Epstein
Current Primary Physician:
Chief Complaints:
. Mr. E steins eaks very
highly of Dr. Merrell and suggest
EFTA00571873
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