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PATIENT INFORMATION Full legal name Date of Birth / / Social Security # Sex Age Today's Date Home Phone Cell Phone Work Phone Mailing Address City State Zip Email Preferred Pharmacy IF PATIENT IS
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Fredericksburg Christian Health Center is a non-profit organization that provides healthcare services to the community.
All individuals and organizations who receive healthcare services from Fredericksburg Christian Health Center are required to file.
To fill out the form, individuals must provide their personal information, medical history, and any insurance information.
The purpose of the center is to provide quality and affordable healthcare services to the community.
Information such as medical history, insurance information, and demographic details must be reported.
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