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Phone: 805.770.8400 (*PLEASE PRINT LEGIBLY)Fax: 805.770.8402PATIENT INFORMATIONPatient Name (First & Last):___ Sex: (circle) M / F Address:___ City:___ State:___ ZIP:___ Social Security Number:_________
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Please print legiblyfax 805 is a form used for submitting legible fax documents.
Any individual or organization that needs to submit fax documents legibly may be required to file please print legiblyfax 805.
Please print legiblyfax 805 form should be filled out by providing the required information in the designated fields.
The purpose of please print legiblyfax 805 is to ensure that fax documents are submitted in a legible format for proper processing.
The information required on please print legiblyfax 805 may include sender details, recipient details, and any additional information relevant to the fax documents being submitted.
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