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AFFORDACARE URGENT CARE CLINIC 801 Early Blvd. Ste. 200 Early, Texas 76802 PHONE 3254300000 FAX 3254300009 PATIENT NAME: SEX: M F DATE OF BIRTH: SSN: ADDRESS: CITY/STATE: ZIP CODE: PHONE: ( ) CELL:(.

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  7. Press Done and save the resulting document.

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