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Page 1 of 2Luke A. Crater, O.NEW PATIENT HISTORY QUESTIONNAIRE GENERAL INFORMATION Last Name: First Name: MI: Preferred Name: Sex: Address: City: State: Zip: Preferred Telephone Number(s): SSN: Date
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To fill out lastname firstnamemi, follow these steps:
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Start by writing your last name in capital letters.
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Leave a space after your last name.
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Write your first name in lowercase letters followed by a space.
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Write the initial of your middle name in uppercase letters.
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