The Wellness Centre                  
  Westshore Medical, Cocorite    
  Trinidad & Tobago     male female  
  Tel: 622-9355  Fax: 622-3289      
   
     
  To:  
   
     
  Re:  
     
  Age:   Phone:  
     
  Please do the following tests on this client and charge to our account.    
  Results should be delivered/faxed to the address above    
         
         
         
   
     
   
     
     
     
       
     
         
   
     
  The Management  
  done      
       
       

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