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PATIENT REGISTRATION Today\'s Date:(Day/Month/Year):___ Full Name: (MrMissMrsMsDr)___I prefer to be addressed as:___ Date of Birth (Day/Month/Year):___ Home Address: ___ City: ___ Postal Code: ___

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Start by entering the current day of the month in the designated space.

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Anyone who needs to provide or reference the current date in a specific format.

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