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MRAcupuncturePC PATIENTINFORMATION Filename: Hostname: M.I.: MailingAddress: State: Zip: Hotel: Cell: Office: Employer: HRS worked: Retired: Email: DOB: / / Age: Sex:Male Female SS#: MaritalStatus:Married

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This form is specifically designed for patients of Mr. Acupuncture who are undergoing the MARA (Minimal Acupuncture Regimen Assessment) treatment.

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