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PATIENT REGISTRATION FORM TODAYS DATE: NAME: FIRST M.I. LAST HOME ADDRESS: City HOME PHONE (CELL PHONE () WORK PHONE () BIRTHDATE: State Zip) EMAIL ADDRESS: AGE RELATIONSHIP STATUS (CIRCLE) SEX (CIRCLE)
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What is today's date?
Today's date is October 17, 2021.
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The purpose of today's date is to mark the current day in time.
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