Kendra Fuller

 
 7609521074 
 16:09:15 11-09-2017 
 6/6 
 Dr Rachel Simmons M.D. 
 74466 Christian Squares Suite 835
North Christineport, ME 64683 
 LAST NAME: 
 Wieczorek FIRST: Kendra Fuller 
 MI 
 NA 
 STREET ADDRESS: 13430 Meteor Dr. CITY Victorville ST CA ZIP 92435 
 MAILING ADDRESS: 8439 SVL Box CITY Victorville ST CA ZIP 92435 
 PHONE: 
 CELL# 202-250-7464 SS# 543-23-7431 M/F F 
 date of birth: 1998-31-12 
 DRIVERS LICENSE#: C8406624 
 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. 
 ELECTRONICALLY SIGNED BY: 
 2020-01-11 
 SIGNED: 
 01/09/2018