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Patient Information Ashley Heroin, D.O.M., L. Ac. 3020 N. Federal Highway, Suite 3 Fort Lauderdale, FL 33306 9545300125 Patient Names: Date of Birth: Age: Male: Female: Single: Married: Separated:
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Long intake forms typically require personal identification details, financial data, relevant legal documents, and any other information pertinent to the specific purpose of the form.
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