Metro House Calls  
by 855 MD 2 HOME
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                            855 MD 2 HOME 

Submitting this form authorizes Metro House calls to charge $99.00 plus your copay to your credit card. If you are uninsured, Metro Medical House calls will charge $250.00 to your credit card.  

First Name:
Last Name:
Address Street 1:
Address Street 2:
Zip Code: (5 digits)
Daytime Phone:
Evening Phone:

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