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PATIENT INFORMATION Last Name: Street Address: First Name & Initial: City: State: Sex: Age: Birth date: Zip Code: Home Phone: Cell: Marital Status: (M) (S) (W) (D) Social Security#: Email address:
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How to fill out street address

01
Start by writing your house or building number on the first line.
02
Write the name of the street on the second line.
03
If applicable, include additional address information such as the apartment or unit number on the third line.
04
Write the name of the city or town on the fourth line.
05
Include the postal or ZIP code on the fifth line.
06
Finally, write the name of the country on the last line.

Who needs street address?

01
Individuals who need to receive mail or packages at their physical location.
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Businesses that require a physical address for their operations.
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Government agencies for official correspondence and document delivery.
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Organizations that need to establish a legal or official presence.
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Emergency services to locate and respond to incidents.
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Online platforms and services that require address verification for user registration.

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