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PATIENT INFORMATION Please print clearly and complete all backdate:REFERRED BY:SEX:NAME:BIRTHDATE: LASTFIRSTMIDDLEMAILING ADDRESS: CITYTELEPHONE: SS #STATEMENT PHONE:WORK NUMBER:MARITAL STATUS:EMPLOYER:EMAIL:

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Please print clearly and refers to the requirement of neatly writing information on a form or document to ensure it is legible.

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Anyone filling out a form or document is required to print clearly to ensure the information can be read and understood.

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What is the purpose of please print clearly and?

The purpose of please print clearly and is to ensure that the information provided is accurate and can be easily understood by others.

What information must be reported on please print clearly and?

Any information requested on the form or document must be reported clearly, including but not limited to name, address, contact information, and relevant details.