er your patients to, in order to receive consultations and treatments for specialists services? O Regional hospital O Regional Medical Surgery 's K Private,ractices 0 Metropolitan Specialists O Surgery currently employed at Please Specify : Pg 1 EFTA00262246 07015 RE_PCRT I NC, II/Frit% ACT/ T

r your patients to, in order to receive consultations and treatments for specialists services? O Regional hospital O Regional Medical Surgery ' s K Private,ractices O Metropolitan Specialists O Surgery currently employed at Please Specify : Pg 1 EFTA00262369 id"(C)t_nis.C,Afrt ri ce.OFFICIatart :

er your patients to, in order to receive consultations and treatments for specialists services? K Regional hospital 0 Regional Medical Surgery 's K Private,ractices 0 Metropolitan Specialists 0 Surgery currently employed at Please Specify : Pg 1 EFTA00268234 t-151c_ coritmea:i1/4091-1(>1 fiuSINEs

oration K Partnership K Simple trust K Complex trust K Estate K Government K Grantor trust K Central bank of issue K Tax-exempt organization K Private foundation K International organization 5 Permanent residence address (street. apt. or suite no.. or rural route). Do not use a M. box or In-ewe-o

oration K ParinerShip K Simple trust K Complex trust K Estate K Government K Grantor trust K Central bank of issue K Tax-exempt organization K Private foundation K International organization 5 Permanent residence address (street. apt. or suite no.. or rural route). Do not use a P.O. box or In-car