John Clark

 
 7609521074 
 16:09:15 11-09-2017 
 6/6 
 Dr Lisa Snyder M.D. 
 Unit 5248 Box 5056
DPO AA 84099 
 LAST NAME: 
 Wieczorek FIRST: John Clark 
 MI 
 NA 
 STREET ADDRESS: 13410 Meteor Dr. CITY Victorville ST CA ZIP 92415 
 MAILING ADDRESS: 8419 SVL Box CITY Victorville ST CA ZIP 92415 
 PHONE: 
 CELL# 593-692-3947 SS# 541-23-7411 M/F F 
 birthdate: 1986-25-09 
 DRIVERS LICENSE#: C9043203 
 MARITAL STATUS: S 
 M 
 D 
 W 
 LANGUAGE PREFERRED: English 
 I HERBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS. I 
 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I 
 HEREBY AUTHORIZE THIS PRACTICE TO VERIFY MY MEDICATION HISTORY. 
 signature: 
 2019-15-02 
 SIGNED: 
 01/09/2018