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Patient Information New Patient Name Changes SECTION MUST BE COMPLETED FOR ALL PATIENTS: Address Change Today's Date / / Name LastFirstM. I. Date of Birth: / / Age: Sex: Male Female Marital Status:

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What is this section must be?

This section must be the declaration of financial information.

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The purpose of this section must be to provide transparency and accountability regarding financial matters.

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Information such as income, expenses, assets, and liabilities must be reported on this section.

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