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PATIENT INFORMATION (PLEASE PRINT CLEARLY) Patient Name: ___ DOB: ___ Age: __ Sex: M of Home Address: ___ A pt #:__ Social Security#:___ City: ___ State: ___ Zip:___ Marital Status:___ Home Phone:

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Patients visiting Texas Allergy Center who need to provide their information in a printable format.

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The form must include information such as medical history, allergies, current medications, and contact details of the patient.

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