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PATIENT NAME: TODAYS DATE: / / DATE OF LOSS: / / Page 1 of 6 PATIENT INTAKE PREMISE LIABILITY PATIENT PERSONAL INFORMATION LAST NAME: FIRST NAME: DATE OF BIRTH: AGE: SOCIAL SECURITY #: ADDRESS: CITY:

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What is today's date?

January 10, 2023

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Simply write down the current date in the format MM/DD/YYYY.

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Any relevant events, activities, or transactions that occurred on the current date.

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