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Patient DOB dd/mm/yyyy Patient PHN Sample Provider MSC and Name copy of report requested locum for Patient Last Name Patient First Name Initials Patient Previous Last Name Cytology Lab ID Sample Date dd/mm/yyyy LMP Date dd/mm/yyyy Follow-up Practitioner / Clinic MSC Name and Address Responsible for Follow-up Copy to MSC Name pls provide address if clinician practices in multiple offices HPV Vaccination SAMPLE SITE No Yes Cervix/endocervix Abnormal Bleeding Vagina vault/wall Post Menopausal...
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