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Patient RegistrationPatient Name Date of Birth Address City, State, Zip Code Phone # SS# Marital Status Sex: M FIF Under 18Name of Parent/Guardian Phone # Parent/Guardian Address City, State, Zip
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City, state, zip code, and phone number are all parts of an address that help identify a specific location.
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Anyone who is providing or updating their contact information may be required to fill out city, state, zip code, and phone number.
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The purpose of providing city, state, zip code, and phone number is to ensure accurate contact information is on file.
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