{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff1\deff0\stshfdbch31505\stshfloch1\stshfhich31506\stshfbi31507\deflang1033\deflangfe1033\themelang1033\themelangfe0\themelangcs0{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f1\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}
{\f1\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}{\flomajor\f31500\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbmajor\f31501\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhimajor\f31502\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0302020204030204}Calibri Light;}
{\fbimajor\f31503\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\flominor\f31504\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbminor\f31505\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}
{\fbiminor\f31507\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}{\f39\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\f40\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\f42\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f43\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f44\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f45\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\f46\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f47\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f49\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\f50\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
{\f52\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\f53\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\f54\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}{\f55\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}
{\f56\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\f57\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}{\f49\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\f50\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
{\f52\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\f53\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\f54\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}{\f55\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}
{\f56\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\f57\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}{\flomajor\f31508\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31528\fbidi \fswiss\fcharset238\fprq2 Calibri Light CE;}
{\fhimajor\f31529\fbidi \fswiss\fcharset204\fprq2 Calibri Light Cyr;}{\fhimajor\f31531\fbidi \fswiss\fcharset161\fprq2 Calibri Light Greek;}{\fhimajor\f31532\fbidi \fswiss\fcharset162\fprq2 Calibri Light Tur;}
{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;}{\fhimajor\f31536\fbidi \fswiss\fcharset163\fprq2 Calibri Light (Vietnamese);}{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}
{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \fswiss\fcharset238\fprq2 Arial CE;}
{\fbiminor\f31579\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}{\fbiminor\f31581\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\fbiminor\f31582\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\fbiminor\f31583\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}
{\fbiminor\f31584\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}{\fbiminor\f31585\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\fbiminor\f31586\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;
\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;
\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;}{\*\defchp \fs22\loch\af1\hich\af31506\dbch\af31505 }{\*\defpap \ql \li0\ri0\sa160\sl259\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 }
\noqfpromote {\stylesheet{\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 \fs20\lang1033\langfe1033\loch\f1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 \snext0 \sqformat \spriority0 Normal;}
{\*\cs10 \additive \ssemihidden \sunhideused \spriority1 Default Paragraph Font;}{\*
\ts11\tsrowd\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\trcbpat1\trcfpat1\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv \ql \li0\ri0\sa160\sl259\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \fs22\lang1033\langfe1033\loch\f1\hich\af31506\dbch\af31505\cgrid\langnp1033\langfenp1033 \snext11 \ssemihidden \sunhideused 
Normal Table;}}{\*\rsidtbl \rsid1335187\rsid13788202}{\mmathPr\mmathFont34\mbrkBin0\mbrkBinSub0\msmallFrac0\mdispDef1\mlMargin0\mrMargin0\mdefJc1\mwrapIndent1440\mintLim0\mnaryLim1}{\info{\author Seven}{\operator Seven}{\creatim\yr2013\mo7\dy17\hr4}
{\revtim\yr2013\mo7\dy17\hr4}{\version2}{\edmins0}{\nofpages1}{\nofwords413}{\nofchars2356}{\nofcharsws2764}{\vern57433}}{\*\xmlnstbl {\xmlns1 http://schemas.microsoft.com/office/word/2003/wordml}}
\paperw12240\paperh15840\margl1260\margr1052\margt1065\margb360\gutter0\ltrsect 
\widowctrl\ftnbj\aenddoc\trackmoves0\trackformatting1\donotembedsysfont0\relyonvml0\donotembedlingdata1\grfdocevents0\validatexml0\showplaceholdtext0\ignoremixedcontent0\saveinvalidxml0\showxmlerrors0\horzdoc\dghspace120\dgvspace120\dghorigin1701
\dgvorigin1984\dghshow0\dgvshow3\jcompress\viewkind1\viewscale100\rsidroot13788202 \fet0{\*\wgrffmtfilter 2450}\ilfomacatclnup0\ltrpar \sectd \ltrsect\sbknone\linex0\cols2\colno1\colw1296\colsr5544\colno2\colw3088\sectdefaultcl\sftnbj {\*\pnseclvl1
\pnucrm\pnqc\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnqc\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnqc\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnqc\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnqc\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnqc\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnqc\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnqc\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnqc\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\ql \li0\ri0\sb14\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat1 \rtlch\fcs1 
\af1\afs20\alang1025 \ltrch\fcs0 \fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af1\afs18 \ltrch\fcs0 \b\fs18\cf8\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Registration }{\rtlch\fcs1 \af1\afs18 
\ltrch\fcs0 \fs18\cf8\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 :}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat1 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \fs22\cf8\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
Asthma & Allergy Medical Care}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn5119\margrsxn1217\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb65\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat1 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn5119\margrsxn1217\sbknone\linex0\cols3\colno1\colw720\colsr1339\colno2\colw1274\colsr1850
\colno3\colw720\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 fChan ID}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li0\ri0\sb14\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
'/jthfjrlfi-\bullet ':'\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 :\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 .'.'"'.; \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 "}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb65\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6
\hich\af1\dbch\af31505\loch\f1 -    \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1    ,;\bullet ";,\bullet .,}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1231\margrsxn1642\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb252\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb65\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn1231\margrsxn1642\sbknone\linex0\cols2\colno1\colw2721\colsr1498
\colno2\colw5148\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li22\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin22\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1335187 
{\shp{\*\shpinst\shpleft-72\shptop-461\shpright-72\shpbottom11347\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz0\shplid1026{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 13970}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251658240}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8192\dpline\dpptx0\dppty0\dpptx0\dppty11808
\dpx-72\dpy-461\dpxsize0\dpysize11808\dplinew22\dplinecor0\dplinecog0\dplinecob0}}}{\shp{\*\shpinst\shpleft4162\shptop274\shpright4162\shpbottom742\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz1\shplid1027
{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn lineWidth}{\sv 4445}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251659264}}
{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8193\dpline\dpptx0\dppty0\dpptx0\dppty468\dpx4162\dpy274\dpxsize0\dpysize468\dplinew7\dplinecor0\dplinecog0\dplinecob0}}}
{\shp{\*\shpinst\shpleft9950\shptop-439\shpright9950\shpbottom13025\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz2\shplid1028{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 13970}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251660288}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8194\dpline\dpptx0\dppty0\dpptx0\dppty13464
\dpx9950\dpy-439\dpxsize0\dpysize13464\dplinew22\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Patient Information}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li36\ri0\nowidctlpar\tx1886\wrapdefault\faauto\rin0\lin36\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Last Name}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 
\fs14\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-2\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 " i First Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb396\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-9\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Address}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li7\ri0\sb338\nowidctlpar\wrapdefault\faauto\rin0\lin7\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Address 2}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\qr \li0\ri0\sb230\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-3\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
Age   ; Social Security }{\rtlch\fcs1 \ai\af1\afs14 \ltrch\fcs0 \i\fs14\expnd0\expndtw-3\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ft}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Middle   ! Gender        f Marital Status    i Birthdate}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li2657\ri0\sb382\nowidctlpar\wrapdefault\faauto\rin0\lin2657\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 How did you hear of us?}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx2542\posy547\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li439\ri4032\sl-238\slmult0\nowidctlpar\wrapdefault\faauto\rin4032\lin439\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I Homo: }{\rtlch\fcs1 \af1\afs14 
\ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I Work: }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 *| Cell: }{\rtlch\fcs1 \ai\af1\afs14 \ltrch\fcs0 
\i\fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \\\hich\af1\dbch\af31505\loch\f1  }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Email:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1238\margrsxn1621\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb36\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li439\ri4032\sl-238\slmult0\nowidctlpar\wrapdefault\faauto\rin4032\lin439\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn1238\margrsxn1621\sbknone\linex0\cols4\colno1\colw1123\colsr1901
\colno2\colw720\colsr0\colno3\colw2541\colsr1908\colno4\colw1202\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li7\ri0\sb43\nowidctlpar\wrapdefault\faauto\rin0\lin7\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1335187 
{\shp{\*\shpinst\shpleft3319\shptop-22\shpright4197\shpbottom-22\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz3\shplid1029{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8890}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251661312}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8195\dpline\dpptx0\dppty0\dpptx878\dppty0
\dpx3319\dpy-22\dpxsize878\dpysize0\dplinew14\dplinecor0\dplinecog0\dplinecob0}}}{\shp{\*\shpinst\shpleft5011\shptop-22\shpright6134\shpbottom-22\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz4\shplid1030
{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn lineWidth}{\sv 4445}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251662336}}
{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8196\dpline\dpptx0\dppty0\dpptx1123\dppty0\dpx5011\dpy-22\dpxsize1123\dpysize0\dplinew7\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af1\afs14 
\ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 City}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb302\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Emergency Contact}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li65\ri0\sb65\nowidctlpar\wrapdefault\faauto\rin0\lin65\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
[State}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tlul\tx598\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs32 \ltrch\fcs0 \b\fs32\cf1\charscalex68\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 J}{\rtlch\fcs1 \ab\af1\afs32 \ltrch\fcs0 
\b\fs32\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li202\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin202\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Phone}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb36\nowidctlpar\tx965\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-9\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 Zip Code}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 (Employer Name & Address}{\rtlch\fcs1 
\af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li965\ri0\sb295\nowidctlpar\wrapdefault\faauto\rin0\lin965\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I Pharmacy}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
^Occupation}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li151\ri0\sb346\nowidctlpar\wrapdefault\faauto\rin0\lin151\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 iPharmacy Phone}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1252\margrsxn3341\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb259\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li151\ri0\sb346\nowidctlpar\wrapdefault\faauto\rin0\lin151\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn1252\margrsxn3341\sbknone\linex0\cols3\colno1\colw770\colsr2578
\colno2\colw1317\colsr1404\colno3\colw1576\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb50\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Physician}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 FamilyPhysician}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb14\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Referring Physician}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\margrsxn1333\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb338\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb14\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\margrsxn1333\sbknone\linex0\cols3\colno1\colw1454\colsr785\colno2\colw2743\colsr1426
\colno3\colw3240\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li7\ri0\sb14\nowidctlpar\wrapdefault\faauto\rin0\lin7\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1335187 
{\shp{\*\shpinst\shpleft6322\shptop324\shpright6322\shpbottom2174\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz5\shplid1031{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8890}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251663360}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8197\dpline\dpptx0\dppty0\dpptx0\dppty1850
\dpx6322\dpy324\dpxsize0\dpysize1850\dplinew14\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-2\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Medical Insurance}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb266\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af0\afs14 \ltrch\fcs0 \f0\fs14\cf1\insrsid1335187 \hich\af0\dbch\af31505\loch\f0 1}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb7\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
Name & Address        }{\rtlch\fcs1 \ab\af1\afs18 \ltrch\fcs0 \b\fs18\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Policyholder}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\tx2513\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
Relationship Policy ID\tab }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Group ID}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1173\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li8006\ri0\sa1375\nowidctlpar\wrapdefault\faauto\rin0\lin8006\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1274\margrsxn1678\sbknone\linex0\cols3\colno1\colw5112\colsr238\colno2\colw1634\colsr943\colno3\colw1360\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 
\rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 \fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1335187 
{\shp{\*\shpinst\shpleft2484\shptop-734\shpright2700\shpbottom-734\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid1032{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8890}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251664384}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8198\dpline\dpptx0\dppty0\dpptx216\dppty0
\dpx2484\dpy-734\dpxsize216\dpysize0\dplinew14\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 G u ara ntbr (Person to be billed, if different than patient)}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posnegx-36\posnegy-29\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 1 Last Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx1987\posnegy-29\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 '- First Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 j Middle  .Gender}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li1397\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin1397\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posnegx-29\posnegy-29\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 Address}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri14\nowidctlpar\wrapdefault\faauto\rin14\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-2\expndtw-11\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 糖心视频:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li158\ri0\sb245\nowidctlpar\wrapdefault\faauto\rin0\lin158\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 iMarital Status j Birthdate}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx929\posy166\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \scaps\fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ..jL}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \fi166\li0\ri662\sl-187\slmult0\nowidctlpar\wrapdefault\faauto\rin662\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\fs28\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 i }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 
\b\fs28\expnd-7\expndtw-91\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash \loch\f1 I\hich\f1 \emdash \emdash }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li1138\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin1138\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Work:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li439\ri0\sb151\nowidctlpar\tldot\tx958\wrapdefault\faauto\rin0\lin439\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\charscalex88\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 '\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\hich\af1\dbch\af31505\loch\f1 :\bullet  }{\rtlch\fcs1 \ab\ai\af1\afs8 \ltrch\fcs0 \b\i\fs8\cf1\charscalex88\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632
\'a6\hich\af1\dbch\af31505\loch\f1 .;:}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\charscalex88\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6
\hich\af1\dbch\af31505\loch\f1  }{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\scaps\fs8\cf1\super\charscalex88\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 :}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\scaps\fs8\cf1\charscalex88\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 t; }{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\charscalex88\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 V}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li338\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin338\itap0 \cbpat8 {\rtlch\fcs1 \ai\af1\afs14 \ltrch\fcs0 \i\fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 
\fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Social Security 0}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb281\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Email:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par \sect }\sectd \ltrsect\marglsxn1173\margrsxn1455\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb288\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb281\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn1173\margrsxn1455\sbknone\linex0\cols4\colno1\colw828\colsr1296\colno2\colw720\colsr353
\colno3\colw3916\colsr317\colno4\colw2181\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\phmrg\posx2938\posy1368\absh-144\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 
\ltrch\fcs0 \fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li65\ri0\sb65\nowidctlpar\wrapdefault\faauto\rin0\lin65\itap0 \cbpat8 {\rtlch\fcs1 \af0\afs14 \ltrch\fcs0 \f0\fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af0\dbch\af31505\loch\f0 City}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li0\ri0\sb274\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 j2 Last Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li58\ri288\sb72\sl-439\slmult0\nowidctlpar\wrapdefault\faauto\rin288\lin58\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Address City}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb511\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
f First Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \fi-425\li425\ri1152\sl-252\slmult0\nowidctlpar\wrapdefault\faauto\rin1152\lin425\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 State   jZip Code j Employer Name & Address }{\rtlch\fcs1 \af1 \ltrch\fcs0 \cf1\charscalex45\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 )}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li1044\ri0\sb22\nowidctlpar\wrapdefault\faauto\rin0\lin1044\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 
 Middle    Gender        s Marital Status : Birthdate}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx3298\posy288\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af0\afs14 \ltrch\fcs0 \f0\fs14\expnd0\expndtw-3\cf1\insrsid1335187 
\hich\af0\dbch\af31505\loch\f0 Work:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li1555\ri0\sb281\nowidctlpar\wrapdefault\faauto\rin0\lin1555\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-9\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I 糖心视频:}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 State   ;Zip Code I Employer Name & Address}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li533\ri0\sb65\nowidctlpar\wrapdefault\faauto\rin0\lin533\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 i Occupation}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li950\ri0\sb302\nowidctlpar\wrapdefault\faauto\rin0\lin950\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 S Social Security }{\rtlch\fcs1 \ai\af1\afs14 
\ltrch\fcs0 \i\fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 U}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx389\posy158\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ""I}{\rtlch\fcs1 
\af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \fi346\li605\ri1152\sb14\sl-223\slmult0\nowidctlpar\wrapdefault\faauto\rin1152\lin605\itap0 \cbpat8 {\rtlch\fcs1 \ab\ai\af1\afs14 \ltrch\fcs0 \b\i\fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 i }{\rtlch\fcs1 \af1\afs14 
\ltrch\fcs0 \fs14\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Email:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Occupation}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par \sect }\sectd \ltrsect\marglsxn1216\margrsxn1829\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb158\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \sect }\sectd \ltrsect\marglsxn1216\margrsxn1829\sbknone\linex0\cols4\colno1\colw2757\colsr29\colno2\colw720\colsr425
\colno3\colw3571\colsr821\colno4\colw871\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\phmrg\posx1145\posy0\absh-129\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 
\ltrch\fcs0 \fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 '}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 
\b\strike\fs8\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 " .}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ' }{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 
\b\strike\fs8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 >i-\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\bullet \hich\af1\dbch\af31505\loch\f1 "\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 -\'bb}{\rtlch\fcs1 \ab\af1\afs8 
\ltrch\fcs0 \b\fs8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 '}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\strike\fs8\cf1\insrsid1335187 -\bullet \bullet \hich\af1\dbch\af31505\loch\f1 ">\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\bullet 
\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\hich\af1\dbch\af31505\loch\f1  --}{\rtlch\fcs1 \ab\af1\afs8 \ltrch\fcs0 \b\fs8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 '}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\phmrg\posx7423\posy619\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs14 \ltrch\fcs0 \b\fs14\expnd-2\expndtw-10\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 ell:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\phmrg\posx7236\posy1404\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 Cell;}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li22\ri0\sl-360\slmult0\nowidctlpar\pvpara\posx0\posy14\absh-720\absw742\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin22\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-9\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 1. Last Name }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Address}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \fs18\expnd0\expndtw-2\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 HIPAA Approved Contacts}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ; First Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par }\pard \ltrpar\ql \li1865\ri0\sb72\nowidctlpar\wrapdefault\faauto\rin0\lin1865\itap0 \cbpat8 {\rtlch\fcs1 \af0\afs14 \ltrch\fcs0 \f0\fs14\expnd0\expndtw-3\cf1\insrsid1335187 \hich\af0\dbch\af31505\loch\f0 \hich\f0 ......L\'84}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx14\posnegy-22\absh-165\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 2. Last Name}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx1915\posy166\absh-281\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \fs24\expnd-5\expndtw-25\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 ...L.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx29\posy389\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\nowrap\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
Address}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li2059\ri0\sl-122\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin2059\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ; First Name }{\rtlch\fcs1 
\ab\ai\af1\afs14 \ltrch\fcs0 \b\i\fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 i}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb569\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
'""fcity"}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li158\ri0\sb598\nowidctlpar\wrapdefault\faauto\rin0\lin158\itap0 \cbpat8 {\rtlch\fcs1 \af0\afs14 \ltrch\fcs0 \f0\fs14\expnd-1\expndtw-9\cf1\insrsid1335187 \hich\af0\dbch\af31505\loch\f0 I City}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sl-1\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs2 \ltrch\fcs0 \fs2\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx2095\posnegy-7\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 i Social Security//}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li50\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin50\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-8\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 [Middle \bullet \bullet  Gender      (Birthdate}{\rtlch\fcs1 
\af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li346\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin346\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li886\ri0\nowidctlpar\tx3341\wrapdefault\faauto\rin0\lin886\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-2\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 'j Stale   jzipCode      [Some:}{\rtlch\fcs1 
\af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \tab \hich\af1\dbch\af31505\loch\f1 jbe}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li2275\ri0\sb151\nowidctlpar\wrapdefault\faauto\rin0\lin2275\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Social Security }{\rtlch\fcs1 \ai\af1\afs14 
\ltrch\fcs0 \i\fs14\expnd-1\expndtw-5\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 tt}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li58\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin58\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-3\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 iMIddlel Gender     'Birthdate}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sl-310\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs50 \ltrch\fcs0 \b\fs50\cf1\dn5\charscalex169\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Q}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\pvpara\posx2167\posy0\absh-166\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-2\expndtw-10\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 糖心视频:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li929\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin929\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 'State   |Zip Code}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb259\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 \column }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
j Relationship}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 I}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \fs16\expnd-3\expndtw-16\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 J Work:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li7\ri0\sb22\nowidctlpar\tlul\tx677\wrapdefault\faauto\rin0\lin7\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\ul\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 t}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 
\fs14\cf1\insrsid1335187 \tab .}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li14\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin14\itap0 \cbpat8 {\rtlch\fcs1 \ai\af1\afs14 \ltrch\fcs0 \i\fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1  }{\rtlch\fcs1 
\af1\afs14 \ltrch\fcs0 \fs14\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Relationship}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li14\ri0\sb245\nowidctlpar\wrapdefault\faauto\rin0\lin14\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd-2\expndtw-12\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 1 Work:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 

\par \sect }\sectd \ltrsect\marglsxn1173\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li101\ri0\sb209\nowidctlpar
\tx403\tldot\tx698\tx1066\tx1253\tx1382\tx1814\tx2117\tx2556\tx2830\tx2966\tx3737\tx3866\tx4126\tx4428\tldot\tx5278\tx5573\tx6120\tx6408\tx6538\tx6840\tx7250\tx8186\tx8330\tx8935\tx9324\tx9655\tx9742\wrapdefault\faauto\rin0\lin101\itap0 \cbpat8 
\rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 \fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\expnd-1\expndtw-6\cf1\insrsid1335187 ,}{\rtlch\fcs1 \ab\af1\afs4 
\ltrch\fcs0 \b\fs4\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 '}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\expnd-1\expndtw-6\cf1\insrsid1335187 .}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\fs4\expnd-1\expndtw-6\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1    }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\u9632\'a6\tab \hich\af1\dbch\af31505\loch\f1 HI        }{
\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 -   '\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\tab \loch\af1\dbch\af31505\hich\f1 
\u9632\'a6\tab \hich\af1\dbch\af31505\loch\f1 I\tab lit\tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\expnd0\expndtw-2\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1       I       
\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 >}{\rtlch\fcs1 
\ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 \'ab\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1   \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6
\hich\af1\dbch\af31505\loch\f1     II \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 |     -}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\strike\fs4\expnd0\expndtw-1\cf1\insrsid1335187 .}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\expnd0\expndtw-1\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1     \loch\af1\dbch\af31505\hich\f1 \u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\fs4\cf1\insrsid1335187 \tab \hich\af1\dbch\af31505\loch\f1 II\tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 >l     \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 \'bb
}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 #}{
\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 \u9632
\'a6\u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\tab \hich\af1\dbch\af31505\loch\f1 I\tab \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1  
\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 '}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 .}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6
\u9632\'a6\tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\expnd0\expndtw-4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \'ab\loch\f1        I}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs4 
\ltrch\fcs0 \b\fs4\expnd3\expndtw19\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 .!}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\expnd3\expndtw19\cf1\insrsid1335187 ,}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\fs4\expnd3\expndtw19\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 ,-!}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\expnd3\expndtw19\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\strike\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash \loch\f1        -\tab .    }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 -}{
\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1    ..        \hich\f1 \emdash }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash }{\rtlch\fcs1 
\ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\hich\af1\dbch\af31505\loch\f1 !\tab .    \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 \emdash \tab \emdash \tab }{\rtlch\fcs1 
\ab\af1\afs4 \ltrch\fcs0 \b\fs4\expnd2\expndtw12\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \u9632\'a6--\loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 
\ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \tab }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 
\loch\af1\dbch\af31505\hich\f1 \emdash }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1     \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\u9632\'a6\hich\af1\dbch\af31505\loch\f1  \hich\f1 \emdash 
\loch\f1  .-\loch\af1\dbch\af31505\hich\f1 \u9632\'a6-\loch\af1\dbch\af31505\hich\f1 \u9632\'a6}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash }{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 
\b\fs4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1       \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\tab \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\tab \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\loch\af1\dbch\af31505\hich\f1 \'ab\loch\f1 
        ..     I}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\strike\fs4\cf1\insrsid1335187 \loch\af1\dbch\af31505\hich\f1 \emdash \loch\f1 H}{\rtlch\fcs1 \ab\af1\afs4 \ltrch\fcs0 \b\fs4\cf1\insrsid1335187 \tab .,\loch\af1\dbch\af31505\hich\f1 \u9632\'a6
......\tab \hich\af1\dbch\af31505\loch\f1 |   ,   \loch\af1\dbch\af31505\hich\f1 \u9632\'a6\u9632\'a6\u9632\'a6\tab .\tab \hich\af1\dbch\af31505\loch\f1 .  , \hich\f1 \emdash \loch\f1  !}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li108\ri0\sb7\nowidctlpar\wrapdefault\faauto\rin0\lin108\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs14 \ltrch\fcs0 \b\fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Patient's or Authorized Person's Signature}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li115\ri0\sb94\sl-173\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin115\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
I the undersigned give my authorization to treat and assign directly to Asthma & Allergy Medical Care , all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved
\hich\af1\dbch\af31505\loch\f1  \hich\af1\dbch\af31505\loch\f1 
and covered charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is
\hich\af1\dbch\af31505\loch\f1  \hich\af1\dbch\af31505\loch\f1 expected at the time of service.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par \sect }\sectd \ltrsect\marglsxn1303\margrsxn1246\sbknone\linex0\colsx60\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb158\sl-173\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 \rtlch\fcs1 \af1\afs20\alang1025 \ltrch\fcs0 
\fs20\lang1033\langfe1033\loch\af1\hich\af1\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1335187 
{\shp{\*\shpinst\shpleft-108\shptop-158\shpright-108\shpbottom1527\shpfhdr0\shpbxmargin\shpbxignore\shpbypara\shpbyignore\shpwr3\shpwrk0\shpfblwtxt1\shpz7\shplid1033{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn lineWidth}{\sv 13970}}{\sp{\sn posrelh}{\sv 0}}{\sp{\sn dhgt}{\sv 251665408}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxmargin\dobypara\dodhgt8199\dpline\dpptx0\dppty0\dpptx0\dppty1685
\dpx-108\dpy-158\dpxsize0\dpysize1685\dplinew22\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
I acknowledge receipt of the Practice's Notice of Privacy Practices. I authorize the Practice to use and disclose my health information for purposes of treating me, obtaining payment for services render\hich\af1\dbch\af31505\loch\f1 
ed to me, and conducting healthcare operations.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\qr \li0\ri0\sl-202\slmult0\nowidctlpar\pvpara\posx2376\posy29\absh-872\absw5342\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs14 \ltrch\fcs0 \b\fs14\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 Asthma & Allergy Medical Care}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \fi86\li2498\ri1267\sl-202\slmult0\nowidctlpar\pvpara\posx2376\posy29\absh-872\absw5342\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin1267\lin2498\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 08 Nassau Road " Huntington, NY }{\rtlch\fcs1 \ab\af1\afs14 \ltrch\fcs0 \b\fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 1}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 
1743}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb86\nowidctlpar\pvpara\posx2376\posy29\absh-872\absw5342\dxfrtext36\dfrmtxtx36\dfrmtxty0\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \ab\af1\afs14 \ltrch\fcs0 \b\fs14\cf1\insrsid1335187 
\hich\af1\dbch\af31505\loch\f1 Please attach all pertinent insurance ID cards for photocopying.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
\par }\pard \ltrpar\ql \li0\ri0\sb65\nowidctlpar\tx2822\wrapdefault\faauto\rin0\lin0\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\expnd0\expndtw-4\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Signature}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 
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\par }\pard \ltrpar\ql \fi-1044\li9007\ri0\sl-202\slmult0\nowidctlpar\wrapdefault\faauto\rin0\lin9007\itap0 \cbpat8 {\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \fs14\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Phone:631-423-5590 }{\rtlch\fcs1 \af1\afs16 
\ltrch\fcs0 \fs16\expnd-1\expndtw-7\cf1\insrsid1335187 \hich\af1\dbch\af31505\loch\f1 Email:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid1335187 
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