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NAME Last First Middle Initial 2. DATE OF BIRTH YYYYMMDD 4. E-MAIL ADDRESS 3. SOCIAL SECURITY NUMBER Last four only 5. TELEPHONE NUMBER SECTION II - CONDITIONS FOR USE OF E-MAIL Health care providers cannot guarantee but will use reasonable means to maintain security and confidentially of electronic mail E-mail information sent and received* You must acknowledge and consent to the following conditions 1. E-mail is not appropriate for urgent or emergency situations. Healthcare providers will res ...

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