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* 1. Today's Date:

Date:

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* 2. First Name:

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* 3. Last Name:

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* 4. Primary Phone Number:

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* 5. Email Address:

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* 6. Alternate Phone Number:

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* 7. Zip Code

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* 8. Do you text?

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* 9. Emergency Contact:

Name:

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* 10. Phone Number:

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* 11. Relationship to you:

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* 12. Alternate Phone:

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* 13. NEED TO KNOW INFORMATION: In emergencies, we may need to share important medical history (such as diabetes, asthma, allergies, seizures, heart issues, etc.) with medical staff. Please list relevant medical history & allergies.

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