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The Health Center of Windermere 4875 Cason Cove Drive - Orlando FL 32811 Phone: 407.420.2090 • Fax: 407.420.5998     Patient's name: Address: City: State: -- AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Your email: Patient's current location: Home Hospital Nursing Facility   If selected, please name:   How did you hear about us? -- Please choose one -- Hospital Home Health Physician Yellow Pages Social Worker Friend Newspaper Internet If not patient filling this form: Name: Relationship with patient: Phone: Day:   Evening: Comments:           Get directions to Health Center of Windermere: STARTING POINT Address or Intersection: City: State: ZIP: Country: Canada United States

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