7715 W. Hillsborough Ave.
Tampa, FL 33615
Tel: 813-887-KIDS (5437)
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Person Financially responsible for account
Has your child ever been diagnosed with or treated for the following?
I, the undersigned parent/legal guardian of this child, certify that the above is accurate and complete to the best of my knowledge. I will notify Dr. Ceino and/or the staff of any changes in the above prior to appointment.
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