Jamie Schmitt

 
 7609521074 
 16:09:15 11-09-2017 
 6/6 
 Dr William Douglas M.D. 
 4936 Daniel Villages
Zacharymouth, NC 25015 
 LAST NAME: 
 Wieczorek FIRST: Jamie Schmitt 
 MI 
 NA 
 STREET ADDRESS: 13710 Meteor Dr. CITY Victorville ST CA ZIP 92715 
 MAILING ADDRESS: 8719 SVL Box CITY Victorville ST CA ZIP 92715 
 PHONE: 
 CELL# 834-300-7850 SS# 571-23-7711 M/F F 
 birthdate: 1997-02-05 
 DRIVERS LICENSE#: C4911709 
 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: 
 2022-09-22 
 SIGNED: 
 01/09/2018