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APPOINTMENT: PRINTABLE We respect your privacy therefore your information will not be shared, sold, rented or exchanged with anyone. Click image to view complete privacy policy  Information About You: Legal First Name:   Legal Last Name:   Residential Address:   City:   State:   Zip/Postal Code:   Country:   Date of Birth: (MM/DD/YYYY) - Optional Preferred Phone #:  * required Work Cell Home Alternate Phone #: Work Cell Home Email Address:    How May We Assist You?: Questions/Comments: If you have any questions or comments, please fill in below Yes I have read disclaimer DISCLAIMER: Messages that you send to us by e-mail may not be secure. If you choose to send any confidential information to us via e-mail, you accept the risk that a third party may intercept and use this information. If this is of an urgent nature concerning your health, please contact your primary care physician, go to the local emergency room, or call 911. While we cannot diagnose or treat via e-mail, we can provide information and help schedule an appointment if necessary. FAX TO: (904) 520-6800 MAIL TO: 7017 AC Skinner Parkway                  Jacksonville, FL 32256     Full name:  * required Email:  * required Comments: Yes I give Florida Center for Breast Conservation permission to communicate medical information with me via email:

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