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323 W.

Navarre St
South Bend, IN 46616
info@fab4dultrasound.com
574-315-6313
Prenatal Verification
Form
This form represents verification of proper prenatal care.
All elective services will be denied without this proof.
Thank you for your cooperation.

DATE:_________________________ CONSUMER:___________________________

DUE DATE:_____________________ PHYSICIAN:___________________________

PHYSICIAN PHONE:__________________________

PHYSICIAN ADDRESS:__________________________________________________

I certify the above listed physician/midwife is my OB practitioner. He/she


has been providing me with routine prenatal care since _______________.
(Date)

Consumer Signature:_____________________________

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