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Get NC DHHS 4103 2017-2024

Pacific Islander □ Unknown □ White 5. Ethnic Origin □ Hispanic Cuban □ Hispanic Mexican American □ Hispanic Other □ Hispanic Puerto Rican □ Not Hispanic/Latino □ Unreported 6. Gender □ Female □ Male 4. Race 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 Copper IUD 7. County of Residence Voluntary Participation and Confidentiality .

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