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Get Dhmh 1140

Es should use forms DHMH 1281 & DHMH 4492.) SEND TO YOUR LOCAL HEALTH DEPARTMENT NAME OF PATIENT LAST FIRST M DATE OF BIRTH MONTH DAY AGE SEX YEAR ETHNICITY (Select independently of RACE) M F HISPANIC or LATINO: TELEPHONE NUMBERS YES NO UNKNOWN RACE (Select one or more. If multiracial, select all that apply) Home: Workplace: ADDRESS UNIT# American Indian/Alaskan Native Hawaiian/Pacific Islander Other (Specify): CITY OR TOWN OCCUPATION OR CON.

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