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PATIENT INFORMATION Patients Last Name:Ethnicity: q Declined q Hispanic or Latino q NonHispanic or Latino q UnknownPrimary Language Spoken:First:Middle:q Mr. q Mrs. Race (optional): q Declined q American
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Q declined is a form or document that indicates a request was denied or refused.
Any individual or organization that needs to formally decline a request is required to file q declined.
Q declined can be filled out by providing a clear explanation of the refusal or denial, along with any relevant supporting information.
The purpose of q declined is to formally document the refusal or denial of a request.
Q declined must include details of the request that was refused, reasons for the refusal, and any relevant dates or reference numbers.
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