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1141 18th Street Denver, CO 80202 3032968527 telephone 3032966133 fax www.briangurinsky.com PATIENT INFORMATION NAME PREFERRED NAME SSN MALEFEMALESINGLEMARRIEDCHILDDATE OF BIRTH PHONE (H) (W)EXT(Cell)

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People who live on are individuals residing in a specific location.

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The individuals responsible for the household or property where the people reside are required to file the information.

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