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Name of the Patient: ___ Date of Birth (mm/dd/YYY): ___SECTION A: NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT Purpose: You have the right to read the Notice of Privacy Practices before you decide
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1du1mi1w46t43xbifb3tow9d-wpenginenetdna-sslcompatient in-take form is a form used to gather information about a patient's medical history, current health status, and any other relevant information.
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Patients are usually provided with the 1du1mi1w46t43xbifb3tow9d-wpenginenetdna-sslcompatient in-take form at the healthcare provider's office and are required to fill it out with accurate information about their medical history and current health status.
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Information such as medical history, current medications, allergies, previous surgeries, and current health issues must be reported on the 1du1mi1w46t43xbifb3tow9d-wpenginenetdna-sslcompatient in-take form.
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