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5112 N. Havana Ave. Tampa, FL 33614 Phone: (813)801-9111 Fax: (813)801-9113 www.AvantGardeUrgentCare.com Patient Intake Form ***NOTIFY THE RECEPTIONIST IMMEDIATELY IF YOU FEEL YOU HAVE A POTENTIALLY

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How to fill out 5112 n:

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8. Once you are satisfied with the form, make a copy of it for your records. Sign and date the form as required, and submit it according to the provided instructions or to the relevant authority.

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