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Hhs. gov/hipaa as well as in the reception area. I further acknowledge that a copy of any amended Notice of Privacy Practices will be available at each appointment. Christopherbrowndo. com 902santafe gmail.com Patient s Last Name First Name Address City State Zip Phone Home Work Cell Age Date of Birth // Email Occupation Referred by Patient s condition Duration of Problem Doctor Doctor s Telephone No. in household If Child Parent or guardian Parent 1 Occupation Parent 2 Occupation Siblings...
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