ssion 10/14/20157:30 AM EDT MRLSPNI MOSKOWITZ, BRUCE W, M.D 6784742 PAYMENT IS DUE AT THE TIME OF SERVICE K Cash K Check K Mastercard K Visa K Amex K Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ 643etal leoPaN