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Get Ah-216a Dt-9113 2004-2024

Irthdate Year Surname and given name(s) of father Month Date of admission: Day Suname and given name(s) of mother Other names used previously I, the undersigned, Name and address In my capacity of User or person authorized Authorize the establishment To send the following information to: Concerning the care or services received during the following period: Such information in contained in the dossier of the above-identified user. This authorization is valid for a period of days .

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