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Birth Date: Employer: Cell Phone: Father s Name: Birth Date: Employer: Cell Phone: Is your child allergic to any medications or foods? Please list: Is your child taking any medications? Please list: Zip: Age: Were there any problems at birth? Alternate: Do you consider your child s development to be? above average average below average SSN: Work Phone: SSN: Work Phone: INSURANCE INFORMATION Name of Insured: DOB / / SSN: Employer: Insurance Carrier: Who has legal custody of this patient?.

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