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(603) 6505261PATIENT HISTORY FORMULAS BRING THIS COMPLETED FORM WITH YOU TO YOUR APPOINTMENTYour Name: Date of Birth:Date you are filling out this form:Who is your physician or provider sending you
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What is Your Name:Date of Birth: Form?

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I am a virtual assistant and do not have a physical form or date of birth.
Individuals are required to file their own date of birth information.
Date of birth information is typically filled out on forms or applications provided by organizations or government agencies.
The purpose of date of birth information is to verify identity and age.
The information that must be reported includes the day, month, and year of birth.
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