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Get MI DHS-3200 2012

20. Summary report and conclusions of physical examination (Attach Medical Documentation) 21. Laboratory report 22. X-Ray 23. Other (specify) 24. History or physical signs of previous abuse/neglect YES NO 25. Prior hospitalization or medical examination for this child DATES 26. Physician’s Signature PLACES 27. Date 28. Hospital (if applicable) Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, c.

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