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Get Confidential Morbidity Report Los Angeles County

BY: (First+Space+Last) TITLE ABBREVIATION FIRST NAME FACILITY/CLINIC NAME SUITE/UNIT NO. FACILITY/CLINIC STREET ADDRESS CLINIC STAMP CITY/TOWN STATE OFFICE TEL. (Enter 999-999-9999 as 9999999999) ZIP CODE OFFICE FAX (Enter 999-999-9999 as 9999999999) PATIENT'S LAST NAME 2 NEW REPORT STATUS: DATE OF REPORT (MMDDYY): M.I. FIRST NAME MEDICAL RECORD NUMBER AGE OCCUPATION BIRTHDAY (MMDDYYYY): PATIENT STREET ADDRESS APT/UNIT NO. CITY/TOWN STATE ZIP CODE DAY TEL. (Enter.

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