Request Appt Single Entry

Name: Theodore (Devin) Doutis   DOB: November 9, 1985  Age: 35 Mobile: (970) 589-3619 Email: tdoutis970@gmail.com Preferred communication method: [46] Preferred LanguageEnglish Address:2220 Linda ln
Grand junction, Colorado 81501
Preferred procedure location: Grand Junction BMI: 28.2 Prescribed Meds:    Allergies:

Consultation

Physician--Consult

Put down deposit
Preferred Location for vasectomy (consultation)
Deposit payment