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May we release information to your physicians 17. May we request information from your physicians guns loud rock music motorcycles 10. Is there a history of hearing loss in your family parents siblings grandparents aunts uncles etc. 15. Does your child have coordination problems If yes please explain 14. Do you feel the need for California Children Services financial aid 16. SIGNED DATE PATIENT OR PARENT IF MINOR PLEASE FILL OUT THE REVERSE SIDE OF THIS SHEET Circle YES or NO for the...
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In some cases, individuals may need to provide their own confidential information for personal or administrative purposes, such as obtaining a passport or a driver's license.
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