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Get NFMRC 779002 2012-2024

Ed prior to making an appointment Date_________________________________ Name Bariatric Patient History Form Age (Name as it appears on your driver’s license.) Ht.__________ Wt.________________ Date of Birth Sex  Race:  American Indian/Alaska Native  Asian  Black/African American  Native Hawaiian/Other Pacific Islander  White  Other Ethnicity:  Hispanic or Latino  Non Hispanic or Latino Mailing Address_______________________________________________________.

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