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MEDICAL RECORD AND HEALTHCARE SUMMARY (To Be Completed by Healthcare Source) Childs Name___ Birth date___ Address___ Phone___ Parent(s) or Guardian___ Phone___ Physician___ Phone___ Physicians Emergency Hospital Affiliation___ THE FOLLOWING TO BE COMPLETED BY THE PHYSICIANDate of last physical examination___ How long have you been seeing the child?___ How frequently do you see this child when he is not ill? ___ Does the child have any allergies (including allergies to medication)?___ Is a
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To be completed by refers to the specific form, document, or process that needs to be finalized by an individual or entity.
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