ALLERGIC TO LATEX (1) ALLERGIC TO: (2) ALLERGIC TO: (Wrap-around) (1) ALLERGIC TO: / ALLERGY (Wrap-around) (1) ALLERGIC TO: CODEINE/SULFA/PENICILLIN (1) ALLERGIC TO: PENICILLIN/CODEINE/SULFA (1) ALLERGIES (1) ALLERGIES []LATEX [] DYE [] TAPE [] OTHER.... (1) ALLERGIES/DRUG REACTIONS (1) ALLERGIES/DRUG REACTIONS NO KNOWN ALLERGIES (1) ALLERGY / ALLERGIC TO: (1) ALLERGY ALERT (1) ALLERIC TO: (Wrap-around) (1) ALLERIC: _____ (1) ATTENTION OFFICE STAFF: CO-PAY $__ COLLECT AT TIME OF VISIT (2) BC/BS (1) BILLS ARE DUE IN 30 DAYS (1) BLUE CROSS (1) CAUTION: YOUR ACCOUNT IS NOW 90 DAYS PAST DUE. PAY NOW AND AVOID COLLECTION ACTION. (1) CONFIDENTIAL (1) CONFIDENTIAL FOR AUTHORIZED PERSONNEL ONLY (1) CO-PAY ___ (1) DIABETIC (2) DNR (1) DOCUMENTATION ATTACHED DO NOT SEPARATE FROM CLAIM (1) FINAL NOTICE *THIS IS THE LAST STATEMENT THAT WILL BE SENT TO YOU. *REMIT PAYMENT IN FULL TODAY! *WE ACCEPT VISA & M (1) FINAL NOTICE IF WE DO NOT RECEIVE YOUR PAYMENT BY ___ WE WILL BE FORCED TO TURN YOUR ACCOUNT OVER FOR COLLECTION. (1) FINAL NOTICE IF WE DO NOT HEAR FROM YOU WITHIN 10 DAYS, THIS ACCOUNT WILL BE TURNED OVER TO OUR COLLECTION AGENCY. (1) FINAL NOTICE! (2) FOR YOUR CONVENIENCE, YOU MAY TRANSFER THIS BALANCE TO YOUR CREDIT CARD ACCOUNT. TO PAY WITH YOUR CREDIT CARD, PLEASE C (1) FRIENDLY REMINDER THIS ACCOUNT IS PAST DUE. YOUR PROMPT ATTENTION IS COURTEOUSLY REQUESTED. (1) HIPAA (1) HMO (1) HMO/PPO (1) IF YOU ARE UNABLE TO PAY IN FULL PLEASE SEND A PARTIAL PAYMENT (1) INSURANCE (1) INSURANCE (Wrap-around) (1) INSURANCE PROVIDER: (1) JUST A FRIENDLY REMINDER THAT YOUR ACCOUNT IS OVERDUE. WON'T YOU PLEASE MAIL YOUR REMITTANCE? (1) MEDICAID (1) MEDICAID (Wrap-around) (1) MEDI-CAL (1) MEDICAL ALERT (3) MEDICAL HISTORY UPDATE (With Fill in Boxes) (1) MEDICARE (1) MEDICARE (Wrap-around) (1) MEDICARE HMO (1) MEDICATION ALLERGY (1) MINOR (1) NAME ALERT (1) NAME ALERT D.O.B._____ (1) NAME ALERT DATE OF BIRTH__ TWO PATIENTS WITH SAME NAME (1) NAME ALERT / BIRTHDATE___ (1) NAME ALERT / TWO PATIENTS WITH SAME NAME (1) NAME ALERT/TWO PATIENTS WITH SAME NAME / NAME ALERT (Wrap-around) (1) NEW INSURANCE COVERAGE? NOTIFY US IMMEDIATELY IF YOUR INSURANCE HAS CHANGED. SEND US THE ID AND GROUP #'S, PHONE NUMBE (1) NO INSURANCE (1) NO KNOWN ALLERGIES (1) PAST DUE PLEASE REMIT TODAY! (1) PAST DUE *YOUR INSURANCE HAS PAID ITS SHARE. *DON'T JEPORADIZE YOUR CREDIT. *PLEASE REMIT TODAY! (1) PAST DUE PLEASE CONTACT US AT ONCE REGARDING YOUR OVERDUE ACCOUNT (1) PAST DUE PROMPT PAYMENT OF THIS BALANCE DUE WILL PRESERVE YOUR GOOD CREDIT RATING. MAIL YOUR CHECK TODAY. (1) PAST DUE WE ACCEPT VISA AND MASTERCARD. CALL OUR OFFICE WITH YOUR CARD NUMBER. (1) PATIENT RECORD CONFIDENTIAL (1) PATIENT RESPONSIBILITY DUE TO: *DEDUCTIBLE *NONCOVERED SERVICES *TOO MANY SERVICES IN TIME PERIOD *MAXIUMUM BENEFIT ALLO (1) PLEASE CONTACT OUR OFFICE REGARDING YOUR OVERDUE BALANCE. WE'D LIKE TO WORK WITH YOU TO DEVELOP A REASONABLE PAYMENT P (1) PRE-MEDICATE (1) PRIOR APPROVAL REQUIRED (1) REGULAR MONTHLY PAYMENTS ARE NECESSARY TO KEEP THIS ACCOUNT CURRENT (1) RESUBMISSION: THIS IS NOT A DUPLICATE BILING. THIS CLAIM HAS EITHER BEEN DENIED OR NEVER RECEIVED. PLEASE CONSIDER FO (1) RH NEGATIVE (1) RUSH (1) SELF PAY (1) SIGN HERE - With Arrow (1) THANK YOU! (1) THIS BALANCE IS OVERDUE! PROMPT PAYMENT WILL AVOID COLLECTION PROCEDURES. (1) THIS BALANCE MAY BE TRANSFERRED TO YOUR VISA OR MASTERCARD JUST CALL US (1) WE ACCEPT VISA AND MASTERCARD. IF YOU WISH TO PAY YOUR ACCOUNT WITH YOUR CREDIT CARD, PLEASE COMPLETE THE FOLLOWING LIN (1) WE HATE TO KEEP HOUNDING YOU, BUT YOUR BILL IS PAST DUE. (1) WE HAVE NOT BEEN PAID ON THIS CLAIM BECAUSE YOUR INSURANCE COMPANY: *SENT PAYMENT TO YOU *APPLIED THESE CHARGES TO YOUR (1) WORKER'S COMP (1) X-RAY NAME:__ NO.__ DATE:__ TAKEN BY:__ KV:__ EXP:__ COMMENTS:__ (1) YOUR ACCOUNT IS PAST DUE. WE WOULD APPRECIATE YOUR PAYMENT TODAY! (1) YOUR BALANCE DUE TO: *YOUR DEDUCTIBLE *NON-COVERED SERVICES *CO-PAY $___ (1) YOUR INSURANCE COMPANY HAS ALREADY PAID ITS SHARE OF YOUR BILL. THIS STATEMENT IS FOR THE AMOUNT YOU OWE. (1) YOUR INSURANCE COMPANY HAS PAID ITS SHARE OF YOUR BILL. THIS STATEMENT IS FOR THE AMOUNT PAYABLE DIRECTLY BY YOU. PLEA (1) ***Will be DISCONTINUED once stock is depleted*** (6)

FLUORESCENT YELLOW (1) GREEN (1) LIGHT BLUE (4) RED (3) WHITE (1) WHITE & BLUE (1) WHITE & RED (3)

1-5/8"W x 7/8"H (3) 1-7/8"W x 3/4"H (1) 2"W x 2"H (2) 2-1/2"W x 2-1/2"H (2) 2-1/4"W x 7/8"H (2) 3"W x 1"H (4) 3"W x 1-1/8"H (1) 3"W x 7/8"H (1) 3/4"H x 1-1/2"W (1) 3-1/4"W x 1-3/4"H (7) 4"W x 2-1/2"H (1) 4"W x 2-5/8"H (1) 5-1/2"W x 1"H (1)

390/ROLL (2) 420/ROLL (2) 500/ROLL (5) 560/ROLL (1)