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Remove item	Product	Price	Quantity	Subtotal
×	Existing Patient History Update Writable	$57.00	Existing Patient History Update Writable quantity	$57.00
×	HIPAA Patient Release and Authorization for Testimonial Use	$37.00	HIPAA Patient Release and Authorization for Testimonial Use quantity	$37.00
×	Rehab Therapy Evaluation Form	$57.00	Rehab Therapy Evaluation Form quantity	$57.00
×	Patient Payment Plan Worksheet	$79.00	Patient Payment Plan Worksheet quantity	$79.00
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Cart totals

Subtotal	$230.00
Total	$230.00