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Date: This letter certifies that I am the Legal guardian Patient Name (if not the maternal parent(s) please supply legal guardianship papers) Legal Guardian Signature Legal Guardian Printed NameConfidential
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It is a form used to report maternal information.
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The purpose is to ensure accurate reporting of maternal information for official records.
What information must be reported on if not form maternal?
Maternal information such as name, date of birth, and relationship.
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