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Get printable form wh 380 e 2015-2024

______________________ Type of practice / Medical specialty: ____________________________________________________________ Telephone: (________)____________________________ Fax:(_________)_____________________________ Page 1 Form WH-380-E Revised May 2015 PART A: MEDICAL FACTS 1. Approximate date condition commenced: ______________________________________________________ Probable duration of condition: ______________________________________________________________ Mark below as applicable: Wa.

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