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Adapted with permission from University of Wisconsin Hospital FORT WAYNE ALLERGY AND ASTHMA CONSULTANTS, INC. PATIENT INFORMATION PLEASE PRINT LAST NAME FIRST NAME M.I. BIRTH DATE TODAY IS DATE: SEX

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Adapted with permission from refers to material that has been modified or changed with the consent of the original copyright holder.

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The purpose of adapted with permission from is to ensure that any modifications made to copyrighted material have been done with the approval of the original copyright holder.

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Information such as the title of the original material, the copyright holder's name, the changes made, and the date of permission granted must be reported on adapted with permission from.