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Page 1Patient Information (Please Print)Patients Name: LastFirstMiddleBirthdate: / / SSN: Gender: Male Female Race: Ethnicity: Preferred Language: Marital Status: Single Married Other: Spouses Name:
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What is where do you prefer?
Where do you prefer refers to the location or destination that an individual or organization favors.
Who is required to file where do you prefer?
Any individual or organization that has a preference for a specific location must file where do you prefer.
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What is the purpose of where do you prefer?
The purpose of where do you prefer is to ascertain the preferred location or destination of an individual or organization.
What information must be reported on where do you prefer?
The information required on where do you prefer is the specific location or destination preferred.
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