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PATIENT REGISTRATION CHILD First Name Last Name M.I. Today's Date / / Date of Birth / / Primary Address (where the child resides) (no P.O. boxes please)City State Zip Code Primary Phone Number Cell
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Child 1 last name is Smith.
The parent or legal guardian of child 1 is required to file their last name.
Child 1 last name should be filled out on any official forms or documents that require it.
The purpose of child 1 last name is to identify them within official records and documents.
Child 1 last name must include the same last name as their parent or legal guardian.
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