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REGISTRATION FORM (Please Print) Today's date:PATIENT INFORMATION Patients last name:First:Is this your legal name? Middle:If not, what is your legal name? Mr. Mrs. Marital status (circle one) Miss

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What is chose clinic becausereferred to?

Chose clinic becausereferred form is used to designate the healthcare provider to whom the patient wishes for their medical records or information to be shared with.

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Patients are required to fill out and file the chose clinic becausereferred form.

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The patient needs to provide their personal information, the chosen clinic or healthcare provider's details, and sign the form to authorize the release of medical records.

What is the purpose of chose clinic becausereferred to?

The purpose of chose clinic becausereferred form is to ensure that the patient's medical records are shared only with the authorized healthcare provider and to maintain patient confidentiality.

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The chose clinic becausereferred form must include patient's name, contact information, chosen healthcare provider's name and contact details, and authorization signature.

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