ervice deliver) 'p. in emergencies). This sample acknowledgment is included for the Practice's use for this purpose.! 279851 2 et 1001- Garfunkel. wild & Trans. PC £.2'd 6aLLTS212T6:01 L£12 MB 212 OW NDINIzIrlTh 1.q>14•MP:WOJ Cr .r.r • Tn.. EFTA00310782 Data HEALTH HISTORY - please check symptoms yo