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Dear Owner/Manager
_____________________________________________
Patient Name
The above named patient has had gastric
bypass surgery which has reduced his/her stomach capacity to less
than 4 ounces. We request that this patient be allowed to purchase a child's portion
_________________________________
Dr Amjad Ali, MD - Hamot Medical Center
Thank You for your cooperation |
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Dear Owner/Manager
_____________________________________________
Patient Name
The above named patient has had Lap-Band® surgery which has reduced his/her stomach capacity to less
than 4 ounces. We request that this patient be allowed to purchase a child's portion
_________________________________
Dr Amjad Ali, MD - Hamot Medical Center
Thank You for your cooperation |
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Dear Owner/Manager
_____________________________________________
Patient Name
The above named patient has had gastric
bypass surgery which has reduced his/her stomach capacity to less
than 4 ounces. We request that this patient be allowed to purchase a child's portion
_________________________________
Dr Rodolfo Arreola, MD - Hamot Medical Center
Thank You for your cooperation |
This card is about the size of a normal credit card.
Print it out, fill in your name, then take it to your surgeon for his
signature.
Have it laminated at your local Kinko's.
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