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ST AFF ONLY : IL DID#: Visit Date: INITIAL QUESTIONNAIRE FORM PATIENTS: Please complete this questionnaire BEFORE coming to the OLD Clinic. Please remember to arrive at least 30 minutes prior to your
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The purpose of staff only is to keep a record of employee information for payroll and tax purposes.
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Employee name, social security number, wages, taxes withheld, and other relevant information must be reported on staff only.
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