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PATIENT REGISTRATION PLEASE PRINT FILL ALL AREAS IN BLACK INK FIRST NAME LAST NAME MIDDLE INITIAL BH BIRTHDATE SEX M F Mailing Address Home Address Social Security Number Home Phone Number (City State
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Step 2: Ensure you have a printer and enough paper to print the form
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Step 4: Review the instructions provided on the form to understand the requirements
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Step 5: Begin filling out the form by entering the necessary information in each field
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Step 6: Use capital letters and print clearly to ensure accuracy
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Step 9: Once you have completed filling out the form, review it again for any errors
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Individuals who are required to provide accurate information for a specific purpose
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