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Print Form Fetal Alcohol Spectrum Disorders Clinic Consultation, Training and Technical Assistance Intake Form Today s date Please complete the form to the best of your ability. All information requested
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As an example, if you are Hispanic: Hispanic/Latino Black. If you are not sure, or have any questions: The name of the clinic or program to which you are referred. The Clinic's location. The clinic names. The phone number of the clinic coordinator. The name or number to which you are referred. The name and information of all other facilities, services and physicians that the person is referred to. The person s Email Address. THE PERSON s DATE OF BIRTH (YYYY-MM-DD) The date the person turned 21, if known. THE PERSON s ADDRESS (this will also be used as her or his clinic ID in the course of the conversation). The Person s Phone Number. The person s Date of Birth. The person s Gender: M F. Note: The gender on the request form is only to be used for confirmation; please include the appropriate gender for the person when scheduling the consultation. The person s height and weight or the approximate weight and height the practitioner will measure when making the appointment. The person s current and past medical, psychiatric and addictions treatment history. The person s Current Medication (if known) if any. All medical history reports, including but not limited to, a complete and up to date medical history and physical examination. If you are under the age of eighteen, the person's parents (and guardian if applicable) must complete the Consent Form. The parent(s) for young juveniles must include contact information. If you are a resident of Florida, please submit a copy of your Certificate of Eligibility for Driver's License and ID Card, or copy of your current or expired driver's license and other photo ID with your application. If you will not be taking the examination by phone or online, please provide a copy of your current Driver's License or ID Card with your application. The Driver's License must have expiration dates that are current at the time of the application. If you have any questions about the forms or requirements of this clinic, please email stunt.

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The best fillabe intake refers to an online form used for reporting certain information to the appropriate authority.
Any individual or organization that meets the criteria set by the authority must file the best fillabe intake.
To fill out the best fillabe intake, you need to access the online form provided by the authority and provide the requested information accurately.
The purpose of the best fillabe intake is to collect and organize specific information for compliance or reporting purposes.
The specific information required to be reported on the best fillabe intake can vary depending on the authority and the purpose of the form. It is essential to carefully review the instructions or guidelines provided by the authority.
The deadline to file the best fillabe intake in 2023 may vary depending on the authority or the specific reporting requirements. It is recommended to refer to the official website or contact the authority for the exact deadline.
The penalty for the late filing of the best fillabe intake can also vary depending on the authority and the specific regulations. It is important to review the applicable laws or contact the authority for details on any potential penalties.
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