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Get CA CDPH 110c 2011

Rting lapses of consciousness or control, Alzheimer's disease or other conditions which may impair the ability to operate a motor vehicle safely (pursuant to H&S 103900). CONDITION BEING REPORTED Patient Name - Last Name First Name MI Ethnicity (check one) Hispanic/Latino Home Address: Number, Street Apt./Unit No. City State Home Telephone Number Cell Telephone Number Birth Date (mm/dd/yyyy) Pregnant? Yes English Spanish Other: ______________ Primary Language No Age Gender Years.

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