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New Medical Information
In the past 3-5 months where have you been treated?
Do you have medical insurance?
Can you provide the name/address/phone number related to the new medical information you wish to provide?
Have you returned to work in any capacity?

In the box below, please add DETAILS about all new medical visits that you have had in the past 3-5 months. Include the following: doctor/hospital/ clinic name and address; dates of treatment or admission; reason for treatment(s) and condition(s) treated or diagnosed. New medications or changes to medications. 

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