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PATIENT INFORMATIONTODAYS DATE:LAST NAME (LEGAL NAME):FIRST NAME (LEGAL NAME):SOCIAL SECURITY #:PREFERRED NAME:DATE OF BIRTH:SEX ASSIGNED AT BIRTH: Male FemaleCURRENT GENDER: Male FemaleGENDER IDENTITY*:

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New sexual orientation refers to the orientation categories that are recognized and protected under laws or policies.

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The information required to be reported on the new sexual orientation form may include details about the individual's sexual orientation and any relevant personal or demographic information.

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