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First name *
Last name *
Patient code
Personal ID
Email
Phone
Home phone
Home address
Region
Raion
Lead
Doctor
Notes
Patient is not paying — add billing person
Billing first name
Billing last name
Billing email
Billing phone
Billing personal ID
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First name *
Last name *
Patient code
Personal ID
Email
Phone
Home phone
Home address
Region
Raion
Lead
Doctor
Notes
Patient is not paying — add billing person
Billing first name
Billing last name
Billing email
Billing phone
Billing personal ID
First contact date
Second contact date
First contact note
Second contact note
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