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Get the free Demographic Sheet (page 1 of 2 Todays Date: PLEASE PRINT

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Tony N. Then, M.D. SOUTHWEST GASTROENTEROLOGY, P.A. Demographic Sheet (page 1 of 3) Today's Date: PLEASE PRINT Last Name First Middle Address City State Zip Home Phone () Cell Phone () Date of Birth
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To fill out the demographic sheet page 1, follow these steps:
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Start by writing your full name in the designated space.
03
Next, provide your date of birth, including the day, month, and year.
04
Indicate your gender by selecting either 'male' or 'female' as applicable.
05
Specify your current address, including the street name, city, state, and zip code.
06
Input your phone number and email address for contact purposes.
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If applicable, provide an alternative phone number or email address.
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Write down your emergency contact details, including the name, relationship, phone number, and address.
09
If you have any known allergies, list them accurately.
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Mention any current medications you are taking, including the dosage and frequency.
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Finally, sign and date the form to confirm its accuracy and completion.

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Demographic sheet page 1 is typically required by healthcare providers, hospitals, or medical facilities.
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It is necessary for patients or individuals seeking medical assistance.
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The form helps healthcare professionals gather important personal and contact information, emergency contact details, and medical history.
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Demographic sheet page 1 is a document used to collect basic information about individuals or entities involved in a certain activity or program, typically for governmental or organizational purposes.
Individuals or organizations that participate in specific programs or activities that require demographic data submission are typically required to file demographic sheet page 1.
To fill out demographic sheet page 1, you need to provide accurate information as requested, including personal or business details, demographic information, and any other required data fields.
The purpose of demographic sheet page 1 is to gather essential demographic data to assist in analysis, reporting, and compliance with regulations.
Information typically reported on demographic sheet page 1 includes name, address, age, gender, race, and other relevant demographic indicators.
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