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Get CORE Occupational Patient Registration - Consent Form

Social Security Number: Date of Birth: Gender: Home Address: Emergency Contact: City, State, ZIP: Emergency Phone: Email Address: Relationship: Home Phone: Employer: Primary Care Physician: Work Phone: Male: Female: Reason for Visit: INFORMATION (MUST be completed for Comprehensive Occupational Resources to perform services) I hereby voluntarily consent to evaluation, medical care, obtaining specimens, and to such treatment, as requested by my employer or prospective employer, a.

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