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CIAN PRIMARY CARE PHYSICIAN PLEASE RETURN THE FORM AS SOON AS POSSIBLE. INPATIENT ADMITTING WILL ENTER THIS INFORMATION PRIOR TO YOUR DAY OF ARRIVAL TO REDUCE YOUR WAITING TIME. THANK YOU. PLEASE PRINT NAME BIRTH DATE Please see Race Code Table on the back for race code description. LAST MONTH FIRST DAY YEAR RACE ETHNICITY MIDDLE S.S.# SEX SINGLE WIDOWED SEPARATED Marital Status DEC DECLINED HIS HISPANIC/LAT NHO NOT HISPANIC/LAT UNK UNKNOWN.

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