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Chris Smith Today's Date: mm/dd/yyyy  Add Procedure/Surgery Please provide as much information as you can in the sections below to describe this procedure/surgery: Name: Date:   /  / mm/dd/yyyy   Performed by: Select Doctor Washington, Robert who performed this procedure/surgery To add doctor to the list please enter: First name: Last name: OR New doctors you enter here will be automatically added to your list of current doctors.   Performed at: Select Facility Good Health Clinic Other where procedure/surgery was performed To add facility to the list please enter: Facility Name: Facility Type: Select Facility Type Outpatient Clinic Urgent-Care Clinic Doctor’s Office Hospital Laboratory Radiology Center Emergency Room Other New facilities you enter here will be automatically added to your list of clinics.