Social Security Help Please fill out this form to help Ms. Miller prepare for your inital consultation.
*First Name
*Last Name
Address 2

*E-Mail address

*Home Phone Cell Phone
*Medical Problems
*Date of Birth
*Are you currently under a physician's care?

When was your last visit?
*What is the last date you were able to work?
*Have you applied for Social Security Benefits?

*If yes have you recieved a determination?

*What was the date of your determination?
Describe the type of work you have done for the past fifteen years.
Additional Remarks:
*Required Field

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Jacksonville, FL 32204-3811

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