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CHILD / ADOLESCENT REGISTRATION INFORMATION (please print) Which professional are you seeing today? Date: PATIENT INFORMATION: Patient Full Name: Age: Sex: M / F (First)(MI)(Last)Address: City: State:
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To fill out emp5628, follow these steps:
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Provide your current marital status and indicate if you have any dependents.
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Specify if you are a Canadian citizen or a permanent resident and provide relevant details.
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If you are a temporary resident, provide information about your permit or authorization in Canada.
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