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Get AZ DE-121 2008-2022

Yr) Date the applicant last saw this doctor or clinic (mo/day/yr) Reasons for visits (medical condition for which applicant had an examination or treatment) Type of treatment (such as surgery, chemotherapy and radiation, if known). If no treatment, write “NONE”. DE-121 (Rev. 1/08) (2) 2b. Identify below any other doctor or clinic the applicant has seen since this medical condition began. Name of doctor or clinic Address Telephone Number (including area code) How often does the applica.

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