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Get FL Simply Healthcare Ob Provider Pregnancy Assessment Form 2011-2024

T s Address Patient s Phone County of Residence ( Health Plan name Provider ID # Provider s Name/ Clinic Name Does this patient consider herself (check all that apply-optional): Caucasian / White African American / Black Hispanic / Latino Asian/Pacific Islander Native American Other: (please list) Due Date / / . MM / DD / YY 1STVISIT 2ND SCREEN Gestational Age weeks Weeks Date Screened . / / / / . MM DD YY MM DD YY th 1. Less than.

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