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Lance Feller, MD, FACE Board Certified in Rheumatology PATIENT REGISTRATION PATIENT Full Name: Age: DOB: Sex: Mailing Address: City: State: Zip: Physical Address: City: State: Zip: (IF P.O. BOX IS
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The patient name is required to be filled out in the specified section of the document.
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Healthcare providers or facilities are required to file the patient name.
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The patient's full legal name as it appears on official identification documents.
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