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I hereby authorize release of medical information in this report to …
WebbPHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) I. FACILITY INFORMATION (To be completed by the licensee/designee) 1. NAME OF … Webblic 701 (8/08) (confidential) 1st 2nd 3rd 4th 5th vaccine polio (opv or ipv) dtp/dtap/ dt/td mmr hib meningitis hepatitis b varicella (diphtheria, tetanus and [acellular] pertussis or … in memoriam gifts loved one
I hereby authorize release of medical information in this report to …
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