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    Patient Implant Card Request Form

    By submitting this form and accepting the terms below, you are requesting that an ID card be created for your patient (indicating patient name, date of surgery, and type of implant). You also authorize the use of your contact information to be included on the card for purposes of verification and validation of authenticity.

    *All fields required

    Surgeon Name:
    Surgeon Address:
    City:
    State: Zipcode:
    Office Phone:
       
    Patient Name:
    Date of Surgery:
    Name of Hospital:
    Type of Implant: Apex Mod Apex K1 Apex K2
    Apex Knee
    Apex Cup Apex ARC PS Knee
    Side of Implant: Right Left Both
    Surgeon Agreement:
    By clicking the box to the left I, (initial here), certify that the patient referenced on this form has provided me with written conesnt for the disclosures of Protected Health Information (as that term is commonly understood) contained on this page, which disclosures are necessary to obtain an implant identification card, and has authorized me to request such an implant identification card on their behalf.
       

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