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- Patient:
- ╠ß≤⌠áεßφσ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á╞Θ≥≤⌠║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á═ΘΣΣ∞σ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- Birth date: ▀▀»▀▀»▀▀ Sex: Male █▀▌ Female █▀▌
- Person responsible for payment:
- ╠ß≤⌠áεßφσ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á╞Θ≥≤⌠║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á═ΘΣΣ∞σ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- Greeting: _____________________________________________________________________
- ╧≥τßεΘ·ß⌠Θ∩ε║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- ááááá┴ΣΣ≥σ≤≤║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- áááááááááááááá▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- áááááááá├Θ⌠∙║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á╙⌠ß⌠σ║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á┌Θ≡║á▀▀▀▀▀▀▀▀▀▀
- ááááá├∩⌡ε⌠≥∙║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀á┴⌠⌠ε║á▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀▀
- Home phone:¿▀▀▀⌐á▀▀▀¡▀▀▀▀ Business phone:¿▀▀▀⌐á▀▀▀¡▀▀▀▀
- Relationship with patient: ____________________________________________________
- Occupation: ____________________________ Employer: ____________________________
- Nearest relative: ______________________ Address: _____________________________
- Who referred you this office? _________________________________________________
- Address: ______________________________________________________________________
- Insurance policy name: _______________________________Number: _________________
- Date of last treatment:▀▀»▀▀»▀▀ Next appointment:▀▀»▀▀»▀▀
- Name of policy holder: ________________________________________________________
- Date:▀▀»▀▀»▀▀
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- 4864 1 11 18 patient_name.LASTNAME -1
- 4352 1 37 18 patient_name.FIRSTNAME -1
- 4608 1 64 15 patient_name.MIDDLENAME -1
- 3 2 17 8 birth_date.DATE 2 47 5 47 -1
- 8 2 41 3 sex_male.YESNO 0 91 2 93 -1
- 8 2 53 3 sex_female.YESNO 0 91 2 93 -1
- 4864 4 11 18 payment_name.LASTNAME -1
- 4352 4 37 18 payment_name.FIRSTNAME -1
- 4608 4 64 15 payment_name.MIDDLENAME -1
- 12 5 10 69 greeting. -1
- 4353 6 14 65 address.ORGANIZATION -1
- 8449 7 14 65 address.ADDRESS1 -1
- 12545 8 14 65 address.ADDRESS2 -1
- 16641 9 14 21 address.CITY -1
- 16897 9 43 20 address.STATE -1
- 17153 9 69 10 address.ZIPCODE -1
- 20737 10 14 30 address.COUNTRY -1
- 20481 10 51 28 address.ATTENTION -1
- 2 11 11 14 home_phone.PHONE 0 40 4 41 5 32 9 45 -1
- 2 11 56 14 business_phone.PHONE 0 40 4 41 5 32 9 45 -1
- 12 12 27 52 relationship. -1
- 12 13 12 28 occupation. -1
- 12 13 51 28 employer. -1
- 12 14 18 22 relative. -1
- 12 14 50 29 relative_address. -1
- 12 15 30 49 referral. -1
- 12 16 9 70 referral_address. -1
- 12 17 23 31 insurance_name. -1
- 12 17 62 17 insurance_number. -1
- 3 18 28 8 last_treatment.DATE 2 47 5 47 -1
- 3 18 71 8 next_appointment.DATE 2 47 5 47 -1
- 12 19 23 56 policy_holder. -1
- 131 20 41 8 date_enter.DATE 2 47 5 47 -1
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