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Get NC DHHS 4103 2012

Ative Hawaiian/Other Pacific Islander □ Unknown  □ White N.C. Department of Health and Human Services Division of Public Health Women's and Children's Health Section Family Planning and Reproductive Health Unit Request and Consent for the IUD Copper T 380A (®) □ Hispanic Cuban  □ Hispanic Mexican American □ Hispanic Other  □ Hispanic Puerto Rican □ Not Hispanic/Latino  □ Unreported □ Female  □ Male 5. Ethnic Origin 6. Gender 7. County of Residence .

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