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S, what is your child allergic to? Yes No Children who have special health care needs are those who have chronic physical, developmental, behavioral or emotional conditions expected to last 12 months or more and who also require health and related services of a type beyond that required by children generally. If your child does have special health care needs please discuss these with your child-care provider. Child s Source of Medical Care/Primary Care Physician s Name: Telephone Number:.

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