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PATIENT INFORMATION Doctor you are seeing today: Glenn G. Fabian, PATIENT Reappointment Displease CHECKMaleFemaleMARITAL STATUSMDBIRTHDATEARE YOU: SAGEWRightLeft HandedAmbidextrousPHEIGHTftinWEIGHTlbsOCCUPATION FT
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The information that must be reported includes the name of the doctor, their specialty, contact information, and the dates of your visits.
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