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I confirm that everything I have disclosed pertaining to my claim is truthful to the best of my knowledge.

I confirm that I was not coached and I was not offered any compensation for this claim.

I understand that my medical records will be obtained for an audit to verify any diagnosis/treatment I have reportedly suffered. If any information I have given is not supported by my medical records, I will be held liable for knowingly providing false information and that the Law Firm will reserve the right to prosecute me criminally for medical fraud to the full extent possib le. This carries a term of up to 5 years in federal prison.

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