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Cup.nature Format:Patient Name:
Address:
Phone: Home:
Cell:
Date of Birth:
Age:
Marital Status: TRM try S try War D Occupation:
Emergency Contact\'s Name:
Physician\'s Name:Height:Weight:City:State:zip:Work:
Email:
Phone:
Phone:Allergies:
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What is r--rt t t?
R--rt t t is a form used to report certain information to the relevant authorities.
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