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ASIAN 2. AFRI CAN AMERICAN 3. WHITE 4. HAWAIIAN/PACIFIC ISLAND 5. OTHER ETHNITICITY CIRCLE ONE 1. NOT HISPANIC OR LATINO 2. ASIAN- INDIAN 3. HISPANIC OR LATINO 4. OTHER EMERGENCY CONTACT NAME PHONE NUMBER PRIVACY CONTACT AME RELATIONSHIPDOB PHARMACY NAME/address PRIMARY CARE PHYSICIAN MEDICAL INSURANCE INFORMATION PLEASE PRESENT INSURANCE CARD AT EACH VISIT If you do not have a current insurance card you...
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