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Work days. (WAC 246-101-101/301) PATIENT INFORMATION LAST NAME FIRST NAME ADDRESS TELEPHONE ( CITY/TOWN STATE DATE OF DIAGNOSIS MIDDLE INITIAL REASON FOR EXAM (Check one) Symptomatic Routine Exam No Symptoms Exposed to Infection ) SEX MO ETHNICITY DAY Male YR RACE Check all that apply Hispanic Non-Hispanic Unknown ZIP CODE DATE OF BIRTH Female MO DAY GENDER OF SEX PARTNERS White Asian Unknown Black Other American Indian/Alaskan Native Native Hawaiian/Other Pacific Islan.

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