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Name (please print): For WHA Use Only Affix Centricity Label Here Date of Birth: Reason for Visit: Last Menstrual Period: Medical History Check any of the following medical conditions that you currently
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Individuals who have been explicitly instructed or authorized to complete the form "for wha use only" by the relevant authority or organization.
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For wha use only is a designation used to indicate that certain information is restricted and can only be accessed or used by specific individuals.
Individuals who are handling sensitive information that is marked as for wha use only are typically required to file for this designation.
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The purpose of for wha use only is to ensure that sensitive information is protected and only accessible to authorized individuals.
Any information that is considered sensitive or confidential and marked as for wha use only must be reported.
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