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DATE: ID#: PATIENT NAME: DATE FB BIRTH: Pleaselistanyd rugallergiesweshouldbeawareof: (it helps attend ESN both area NYC rug allergies, p lease rite none) MEDICATIONS Pleaseprovideallcurrentprescriptionsandoverthecounter
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Date id can be filled out by entering the specific date in the designated format.
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Date id typically only includes the date in a specific format.
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