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PATIENT INFORMATION FORM Welcome to our office. Please take a few minutes to complete both sides of this form so that we may have this information for our records. NAME: BIRTH DATE: DATE: ADDRESS:

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This information is used for internal record keeping and compliance purposes.

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All employees are required to file this information.

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The purpose of this information is to ensure accuracy and compliance with regulations.

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Employees must report their personal and financial information.

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