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Get and Sign Sc Dhec Reporting Form 2021-2022
If appropriate): _________________________________________________ Today’s Date____________________________
Ethnicity
Last Name
First Name
Hispanic
Non-Hispanic
Unknown
Middle Name
Patient ID or last five digits of SSN: ________________________ DOB: ______/______/______________
Street Address
State
Preferred Contact Number (
Zip
County
) _________-_________________
Date of diagnosis/bite: ________/_________/_______________
Date of symptom onset:...
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