VERIFICATION OF NON-PREGNANCY

DATE:______________________________________

NAME:_____________________________________

ADDRESS:__________________________________

TELEPHONE:________________________________

SOCIAL SECURITY:__________________________

By my signature on this form, I, __________________

_________________ do hereby state that, to the best of my knowledge,

I am not pregnant, nor is pregnancy suspected or confirmed at this particular time.

PATIENT SIGNATURE_________________________

WITNESS: ___________________________________

WITNESS: ___________________________________