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Have you noticed any of these warning signs? Please list any concerns you have and take this sheet with you to the doctor. Note: This list is for information only and not a substitute for a consultation
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Please specify the concerns that need to be addressed.
Individuals or entities required to file must submit the concerns.
Provide a detailed description of the concerns in the appropriate fields.
The purpose of listing concerns is to address and resolve any issues.
All relevant information related to the concerns must be reported.
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