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T Name: Gender Intake Phone 651-662-5200 or 800-262-0820 *** TYPE ALL INFORMATION OR PRINT LEGIBLY*** Last Name: than twin. Date of Birth Intake Fax Fax Number Mother Birth Status Blue Plus Intake Fax Birth Order & Weight # of Weight Yr Last: Transfer Date Care Level Normal Vag Del Level 1 Normal C-Sec Level 1 Complex Newborn Level 2 Neonatal ICU Level 3 Middle: Baby Diagnosis Code & Ges.

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