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HEALTH HISTORY Patients name___ Address:___ City:___State___ Zip: ___ Birth Date: ___Cell Phone:___Home Phone___Work Phone: ___ Ext.___ General Dentist:___Referred By (same [ ]):___ Physician:___Phone:___In
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Start by entering your street address in the designated field.
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Next, input the name of your city in the city field.
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Then, type in the abbreviation for your state in the state field.
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Lastly, provide your zip code in the zip code field.
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Address citystate zip refers to the location of a specific address, including the city, state, and zip code.
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Anyone who needs to provide their address for official purposes, such as on a form or document, is required to fill out address citystate zip.
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