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TFORD, CT 06134 0308 ALIEN #: VOICE: (860) 509 7722 FAX: DATE OF HEALTH ASSESSMENT: (860) 509 7743 PATIENT'S NAME: LAST, FIRST, MIDDLE MM DATE OF BIRTH: M STREET ADDRESS: CITY: RACE (PLEASE CHECK ALL THAT APPLY): ETHNIC ORIGIN: HISPANIC NON HISPANIC AMERICAN INDIAN/ALASKA NATIVE STATE: DD YYYY MM DD HOME TELEPHONE: SEX: YYYY F ZIP: COUNTRY OF BIRTH: U.S. ENTRY DATE: MM DD YYYY OVERSEAS TB CLASS A, B1, OR B2 STATUS? (REVIEW OVERSEAS DOCUMENTS) ASIAN BLACK OR AFRICAN.

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