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Physician: ___Patient: ___DOB: ___Insurance Provider/Number: ___SS#: ___Contact Information (Name, Number): ___General Admission CriteriaLiver Disease PT 5 seconds/INR 1.5 Serum Albumin 2.5 gm/DL
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How to fill out date of birth street
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Locate the section on the form that asks for the date of birth.
02
Enter the numerical value for the day in the designated space.
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Enter the numerical value for the month in the designated space.
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Enter the numerical value for the year in the designated space.
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Make sure to follow the specified format for the date of birth (e.g. DD/MM/YYYY or MM/DD/YYYY).
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