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I - PATIENT DATA 1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 4. E-MAIL ADDRESS 3. SOCIAL SECURITY NUMBER (Last four only) 5. TELEPHONE NUMBER SECTION II - CONDITIONS FOR USE OF E-MAIL Health care providers cannot guarantee but will use reasonable means to maintain security and confidentially of electronic mail (E-mail) information sent and received. You must acknowledge and consent to the following conditions: 1. E-mail is not appropriate for urgent or emergency situ.

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