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Patient Outcome Form

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Patient Outcome Form

Doctor*

Doctor's Email*

Patient*

Patient's Email*

Patient visit*

Diagnosis (Check all that Apply)*

Which treatment did you recommend? (Check all that apply)*

Please circle the (closest) cost of care you provided for the initial ACS patient visit?*

Please circle any subsequent costs you anticipate for the initial ACS patient visit. (e.g. surgeon's fees, ongoing care for one year within the program)*