5
Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MD Marco E. Bosquez, MD S. Brent Brotzman, MD Jeffrey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD Michael E. Putney, MD Stephen Rose, MD Mustasim N. Rumi, MD Michael S. Valastro, MD Steve C. Wilson, MD 16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498 12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-0000 1401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480

Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD

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Page 1: Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD

Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD

Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD

Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD

16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498

12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480

•••••••

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Page 2: Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD

Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD

Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD

Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD

16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498

12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480

Page 3: Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD

Patient Signature Date

Print Name

Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD

Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD

Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD

16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498

12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480

Page 4: Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD
Page 5: Humayun Beg, MD Je˜rey G. DeLoach, DO Stephen Rose, MD ... · S. Brent Brotzman, MD Je˜rey G. DeLoach, DO David O. Gillory III, MD Robert D. Graham, II, MD Mark S. Parrella, MD

Pre-Op Clearance Information

Humayun Beg, MD Rajshri Bolson, MD Jay M. Borick, MDMarco E. Bosquez, MDS. Brent Brotzman, MD

Je�rey G. DeLoach, DODavid O. Gillory III, MDRobert D. Graham, II, MDMark S. Parrella, MD Michael E. Putney, MD

Stephen Rose, MDMustasim N. Rumi, MDMichael S. Valastro, MDSteve C. Wilson, MD

16020 Park Valley Drive • Round Rock, TX 78681 • (512) 244-0766 4112 Links Lane, Ste. 101 • Round Rock, TX 78664 • (512) 744-6498

12309 North Mopac, Ste. 150 • Austin, TX 78758 • (512) 977-00001401 Medical Parkway, Bldg. C, Ste. 100 • Cedar Park, TX 78613 • (512) 744-6480