"*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.New Patient FormPlease fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.Date: Month010203040506070809101112Day01020304050607080910111213141516171819202122232425262728293031Year20182019202020212022202320242025202620272028Patient #TitleMr.Ms.Mrs.Dr.First Name*Middle Name*Last_Name*I prefer to be called:SexMFAgeMarital Status:MinorSingleMarriedLong-Term PartnerDivorcedWidowedSeparatedDate of Birth: Month010203040506070809101112Day01020304050607080910111213141516171819202122232425262728293031Year20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Social Security #Drivers License StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYDrivers License #Home Phone*Work PhoneCell PhoneEmail AddressHome Address:City:State:ALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYZIP:Employment Status:NoneFull-TimePart-TimeRetiredEmployer's NameEmployer's Phone:Occupation:Employer's AddressCity:State:ALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYZIP:Student_StatusNot a StudentFull-TimePart-TimeStudent_Status_txtSchool_NameGradeBest_ContactReminder_1 First Choice Second Choice Third Choice Reminder_2 First Choice Second Choice Third Choice Reminder_3 First Choice Second Choice Third Choice How_Found1 First Choice Second Choice Third Choice How_Found1_textHow_Found2 First Choice Second Choice Third Choice How_Found3 First Choice Second Choice Third Choice How_Found4 First Choice Second Choice Third Choice How_Found5 First Choice Second Choice Third Choice How_Found6 First Choice Second Choice Third Choice How_Found7 First Choice Second Choice Third Choice How_Found8 First Choice Second Choice Third Choice How_Found9 First Choice Second Choice Third Choice How_Found10 First Choice Second Choice Third Choice How_Found10_textHow_Found11 First Choice Second Choice Third Choice How_Found11_textwebsite_factor website_factor website_factor Spouse_Parent_NameSpouse_Parent_Employer_NameSpouse_Parent_Work_Phone_1Spouse_Parent_Work_Phone_2Spouse_Parent_Work_Phone_3Spouse_Parent_Cell_Phone_1Spouse_Parent_Cell_Phone_2Spouse_Parent_Cell_Phone_3Additional_Family_MembersCommentsEmergency_Contact_TitleMr.Ms.Mrs.Dr.Emergency_Contact_Title_txtEmergency_Contact_First_NameEmergency_Contact_Last_NameEmergency_Contact_RelationshipEmergency_Contact_Phone_Home_1Emergency_Contact_Phone_Home_2Emergency_Contact_Phone_Home_3Emergency_Contact_Phone_Work_1Emergency_Contact_Phone_Work_2Emergency_Contact_Phone_Work_3Emergency_Contact_Phone_Cell_1Emergency_Contact_Phone_Cell_2Emergency_Contact_Phone_Cell_3Emergency_Contact_EmailEmergency_Contact_AddressEmergency_Contact_CityEmergency_Contact_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYEmergency_Contact_State_txtEmergency_Contact_ZIPResponsible_Person_TitleMr.Ms.Mrs.Dr.Responsible_Person_Title_txtResponsible_Person_First_NameResponsible_Person_Middle_NameResponsible_Person_Last_NameResponsible_Person_RelationshipResponsible_Person_DOB_m010203040506070809101112Responsible_Person_DOB_m_txtResponsible_Person_DOB_d01020304050607080910111213141516171819202122232425262728293031Responsible_Person_DOB_d_txtResponsible_Person_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Responsible_Person_DOB_y_txtResponsible_Person_SSN_1Responsible_Person_SSN_2Responsible_Person_SSN_3Responsible_Person_DL_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYResponsible_Person_DL_State_txtResponsible_Person_DL_NumberResponsible_Person_InsuranceNoYes: Primary Insurance PolicyYes: Secondary Insurance PolicyResponsible_Person_Insurance_txtResponsible_Person_Phone_Home_1Responsible_Person_Phone_Home_2Responsible_Person_Phone_Home_3Responsible_Person_Phone_Work_1Responsible_Person_Phone_Work_2Responsible_Person_Phone_Work_3Responsible_Person_Phone_Cell_1Responsible_Person_Phone_Cell_2Responsible_Person_Phone_Cell_3Responsible_Person_EmailBilling_AddressBilling_CityBilling_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYBilling_State_txtBilling_ZIPResponsible_Person_Employment_StatusNoneFull-TimePart-TimeRetiredResponsible_Person_Employment_Status_txtResponsible_Person_Employer_NameResponsible_Person_Phone_Employer_1Responsible_Person_Phone_Employer_2Responsible_Person_Phone_Employer_3Responsible_Person_OccupationResponsible_Person_Work_AddressResponsible_Person_Work_CityResponsible_Person_Work_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYResponsible_Person_Work_State_txtResponsible_Person_Work_ZIPPrimary_Insurance_NamePrimary_Insurance_DOB_m010203040506070809101112Primary_Insurance_DOB_m_txtPrimary_Insurance_DOB_d01020304050607080910111213141516171819202122232425262728293031Primary_Insurance_DOB_d_txtPrimary_Insurance_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Primary_Insurance_DOB_y_txtPrimary_Insurance_RelationshipPrimary_Insurance_EmployerPrimary_Insurance_Member_IDPrimary_Insurance_Group_IDPrimary_Insurance_Company_NamePrimary_Insurance_Phone_1Primary_Insurance_Phone_2Primary_Insurance_Phone_3Primary_Insurance_SSNPrimary_Insurance_AddressPrimary_Insurance_CityPrimary_Insurance_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYPrimary_Insurance_State_txtPrimary_Insurance_ZIPSecondary_Insurance_NameSecondary_Insurance_DOB_m010203040506070809101112Secondary_Insurance_DOB_m_txtSecondary_Insurance_DOB_d01020304050607080910111213141516171819202122232425262728293031Secondary_Insurance_DOB_d_txtSecondary_Insurance_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Secondary_Insurance_DOB_y_txtSecondary_Insurance_RelationshipSecondary_Insurance_EmployerSecondary_Insurance_Member_IDSecondary_Insurance_Group_IDSecondary_Insurance_Company_NameSecondary_Insurance_Phone_1Secondary_Insurance_Phone_2Secondary_Insurance_Phone_3Secondary_Insurance_SSNSecondary_Insurance_AddressSecondary_Insurance_CitySecondary_Insurance_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYSecondary_Insurance_State_txtSecondary_Insurance_ZIPInsurance_Consent_SignatureInsurance_Consent_Signature_m010203040506070809101112Insurance_Consent_Signature_m_txtInsurance_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031Insurance_Consent_Signature_d_txtInsurance_Consent_Signature_y20182019202020212022202320242025202620272028Insurance_Consent_Signature_y_txtPatient_Name_ConsentTreatment_Consent_SignatureTreatment_Consent_Signature_m010203040506070809101112Treatment_Consent_Signature_m_txtTreatment_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031Treatment_Consent_Signature_d_txtTreatment_Consent_Signature_y20182019202020212022202320242025202620272028Treatment_Consent_Signature_y_txtPatient_Name_PaymentPayment_Policies_SignaturePayment_Policies_Signature_m010203040506070809101112Payment_Policies_Signature_m_txtPayment_Policies_Signature_d01020304050607080910111213141516171819202122232425262728293031Payment_Policies_Signature_d_txtPayment_Policies_Signature_y20182019202020212022202320242025202620272028Payment_Policies_Signature_y_txtgeneral_health general_health general_health general_health current_treatmentYesNocurrent_treatment_txtcurrent_treatment_detailsantibiotic_premedicationYesNoantibiotic_premedication_txtantibiotic_premedication_detailsphysician_Namephysician_Phone_1physician_Phone_2physician_Phone_3physician_Last_Visit_m010203040506070809101112physician_Last_Visit_m_txtphysician_Last_Visit_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886physician_Last_Visit_y_txtcontact_physician contact_physician contact_physician MH_HaveYouEverHad_Arthritis First Choice Second Choice Third Choice MH_HaveYouEverHad_Arteriosclerosis First Choice Second Choice Third Choice MH_HaveYouEverHad_Birth_defects First Choice Second Choice Third Choice MH_HaveYouEverHad_Cancer First Choice Second Choice Third Choice MH_HaveYouEverHad_Emotional_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Head_or_face_injury First Choice Second Choice Third Choice MH_HaveYouEverHad_Heart_murmur_trouble First Choice Second Choice Third Choice MH_HaveYouEverHad_History_of_substance_abuse_drug_addiction First Choice Second Choice Third Choice MH_HaveYouEverHad_Kidney_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Numbness_of_arms_or_hands First Choice Second Choice Third Choice MH_HaveYouEverHad_Swollen_still_painful_joints First Choice Second Choice Third Choice MH_HaveYouEverHad_Allergies First Choice Second Choice Third Choice MH_HaveYouEverHad_Asthma First Choice Second Choice Third Choice MH_HaveYouEverHad_Blood_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Diabetes First Choice Second Choice Third Choice MH_HaveYouEverHad_Endocrine_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Intestinal_disorders First Choice Second Choice Third Choice MH_HaveYouEverHad_Hepatitis_a_b_or_c First Choice Second Choice Third Choice MH_HaveYouEverHad_Hypertension_high_blood_pressure First Choice Second Choice Third Choice MH_HaveYouEverHad_Liver_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Pneumonia First Choice Second Choice Third Choice MH_HaveYouEverHad_Shortness_of_breath First Choice Second Choice Third Choice MH_HaveYouEverHad_Anemia First Choice Second Choice Third Choice MH_HaveYouEverHad_Bruise_easily First Choice Second Choice Third Choice MH_HaveYouEverHad_Dizziness First Choice Second Choice Third Choice MH_HaveYouEverHad_Epilepsy First Choice Second Choice Third Choice MH_HaveYouEverHad_Seizures First Choice Second Choice Third Choice MH_HaveYouEverHad_Fainting First Choice Second Choice Third Choice MH_HaveYouEverHad_Hearing_disorders First Choice Second Choice Third Choice MH_HaveYouEverHad_High_or_low_blood_sugar First Choice Second Choice Third Choice MH_HaveYouEverHad_Hypotension_low_blood_pressure First Choice Second Choice Third Choice MH_HaveYouEverHad_Nervous_disorder First Choice Second Choice Third Choice MH_HaveYouEverHad_Rheumatic_fever First Choice Second Choice Third Choice MH_HaveYouEverHad_Heart_attack_stroke First Choice Second Choice Third Choice MH_HaveYouEverHad_Heart_surgery First Choice Second Choice Third Choice MH_HaveYouEverHad_Pacemaker First Choice Second Choice Third Choice MH_HaveYouEverHad_Artificial_valves First Choice Second Choice Third Choice MH_HaveYouEverHad_Congenital_heart_defect First Choice Second Choice Third Choice MH_HaveYouEverHad_Mitral_valve_prolapse First Choice Second Choice Third Choice MH_HaveYouEverHad_Artificial_bones_joints First Choice Second Choice Third Choice MH_HaveYouEverHad_Shingles First Choice Second Choice Third Choice MH_HaveYouEverHad_HIV_AIDS First Choice Second Choice Third Choice MH_HaveYouEverHad_Blood_transfusions First Choice Second Choice Third Choice MH_HaveYouEverHad_Fever_blisters First Choice Second Choice Third Choice MH_HaveYouEverHad_Sinus_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Severe_frequent_headaches First Choice Second Choice Third Choice MH_HaveYouEverHad_Cancer_chemotherapy First Choice Second Choice Third Choice MH_HaveYouEverHad_Radiation_treatments First Choice Second Choice Third Choice MH_HaveYouEverHad_Psychiatric_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Tuberculosis First Choice Second Choice Third Choice MH_HaveYouEverHad_Venereal_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Hemophilia First Choice Second Choice Third Choice MH_HaveYouEverHad_Abnormal_bleeding First Choice Second Choice Third Choice MH_HaveYouEverHad_Ulcers_colitis First Choice Second Choice Third Choice MH_HaveYouEverHad_Difficulty_breathing First Choice Second Choice Third Choice MH_HaveYouEverHad_Hospitalized_for_any_reason First Choice Second Choice Third Choice MH_HaveYouEverHad_Emphysema First Choice Second Choice Third Choice MH_HaveYouEverHad_Glaucoma First Choice Second Choice Third Choice MH_HaveYouEverHad_Thyroid_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Angina First Choice Second Choice Third Choice MH_HaveYouEverHad_Artificial_hip_joints First Choice Second Choice Third Choice MH_HaveYouEverHad_Gout First Choice Second Choice Third Choice MH_HaveYouEverHad_Chest_pain First Choice Second Choice Third Choice MH_HaveYouEverHad_Circulatory_problems First Choice Second Choice Third Choice MH_HaveYouEverHad_Cold_sores First Choice Second Choice Third Choice MH_HaveYouEverHad_Congenital_heart_lesion First Choice Second Choice Third Choice MH_HaveYouEverHad_Cortisone_medicine First Choice Second Choice Third Choice MH_HaveYouEverHad_Convulsions First Choice Second Choice Third Choice MH_HaveYouEverHad_Herpes First Choice Second Choice Third Choice MH_HaveYouEverHad_Leukemia First Choice Second Choice Third Choice MH_HaveYouEverHad_Excessive_thirst First Choice Second Choice Third Choice MH_HaveYouEverHad_Hay_fever First Choice Second Choice Third Choice MH_HaveYouEverHad_Heart_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Hives_skin_rash First Choice Second Choice Third Choice MH_HaveYouEverHad_Hypoglycemia First Choice Second Choice Third Choice MH_HaveYouEverHad_Irregular_heartbeat First Choice Second Choice Third Choice MH_HaveYouEverHad_Lung_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Osteoporosis First Choice Second Choice Third Choice MH_HaveYouEverHad_Pain_in_jaw_joints First Choice Second Choice Third Choice MH_HaveYouEverHad_Parathyroid_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Recent_weight_loss First Choice Second Choice Third Choice MH_HaveYouEverHad_Rheumatism First Choice Second Choice Third Choice MH_HaveYouEverHad_Scarlet_fever First Choice Second Choice Third Choice MH_HaveYouEverHad_Sexually_transmitted_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Sickle_cell_anemia First Choice Second Choice Third Choice MH_HaveYouEverHad_Sinus_trouble First Choice Second Choice Third Choice MH_HaveYouEverHad_Tattoos_body_piercing First Choice Second Choice Third Choice MH_HaveYouEverHad_Tmd_tmj_jaw_pain First Choice Second Choice Third Choice MH_HaveYouEverHad_X-ray_or_cobalt_treatment First Choice Second Choice Third Choice MH_HaveYouEverHad_Yellow_jaundice First Choice Second Choice Third Choice MH_HaveYouEverHad_Chronic_fatigue_syndrome First Choice Second Choice Third Choice MH_HaveYouEverHad_Cough-persistent_or_bloody First Choice Second Choice Third Choice MH_HaveYouEverHad_Latex_sensitivity First Choice Second Choice Third Choice MH_HaveYouEverHad_Smoker First Choice Second Choice Third Choice MH_HaveYouEverHad_Swelling_of_feet_ankles First Choice Second Choice Third Choice MH_HaveYouEverHad_Swollen_neck_glands First Choice Second Choice Third Choice MH_HaveYouEverHad_Tonsillitis First Choice Second Choice Third Choice MH_HaveYouEverHad_Tumor_or_growth_on_head_neck First Choice Second Choice Third Choice MH_HaveYouEverHad_Easily_winded First Choice Second Choice Third Choice MH_HaveYouEverHad_Anaphylaxis First Choice Second Choice Third Choice MH_HaveYouEverHad_Alzheimers_disease First Choice Second Choice Third Choice MH_HaveYouEverHad_Frequent_diarrhea First Choice Second Choice Third Choice MH_HaveYouEverHad_Genital_herpes First Choice Second Choice Third Choice MH_HaveYouEverHad_Renal_dialysis First Choice Second Choice Third Choice MH_HaveYouEverHad_Spina_bifida First Choice Second Choice Third Choice MH_reaction_to_Acrylic First Choice Second Choice Third Choice MH_reaction_to_Aspirin First Choice Second Choice Third Choice MH_reaction_to_Barbiturates_sleeping_pills First Choice Second Choice Third Choice MH_reaction_to_Codeine First Choice Second Choice Third Choice MH_reaction_to_Dental_anesthetics First Choice Second Choice Third Choice MH_reaction_to_Erythromycin First Choice Second Choice Third Choice MH_reaction_to_Iodine First Choice Second Choice Third Choice MH_reaction_to_Latex_rubber First Choice Second Choice Third Choice MH_reaction_to_Metals First Choice Second Choice Third Choice MH_reaction_to_Nitrous_oxide First Choice Second Choice Third Choice MH_reaction_to_Novocain First Choice Second Choice Third Choice MH_reaction_to_Penicillin/antibiotics First Choice Second Choice Third Choice MH_reaction_to_Sedatives First Choice Second Choice Third Choice MH_reaction_to_Sulfa_drugs First Choice Second Choice Third Choice MH_reaction_to_Tetracycline First Choice Second Choice Third Choice MH_reaction_to_Valium First Choice Second Choice Third Choice MH_reaction_to_Xylocaine First Choice Second Choice Third Choice cancerYesNocancer_txtcancer_detailsbisphosphonate_drugs bisphosphonate_drugs bisphosphonate_drugs phenfen phenfen phenfen tobacco tobacco tobacco alcohol_drugs alcohol_drugs alcohol_drugs contact_lenses contact_lenses contact_lenses special_diet special_diet special_diet ten_pounds ten_pounds ten_pounds pillows pillows pillows excessive_bleeding excessive_bleeding excessive_bleeding shortness_of_breath shortness_of_breath shortness_of_breath hospital hospital hospital female_pregnant First Choice Second Choice Third Choice female_pregnant_textfemale_trying First Choice Second Choice Third Choice female_nursing First Choice Second Choice Third Choice female_birth_control First Choice Second Choice Third Choice Prescriptions_ListSerious_ConditionsMedical_History_SignatureMedical_History_Signature_m010203040506070809101112Medical_History_Signature_m_txtMedical_History_Signature_d01020304050607080910111213141516171819202122232425262728293031Medical_History_Signature_d_txtMedical_History_Signature_y20182019202020212022202320242025202620272028Medical_History_Signature_y_txtReviewed_ByReviewed_By_TitleReviewed_m010203040506070809101112Reviewed_m_txtReviewed_d01020304050607080910111213141516171819202122232425262728293031Reviewed_d_txtReviewed_y20182019202020212022202320242025202620272028Reviewed_y_txtHIPAA_Share_Name_1HIPAA_Share_Relationship_1HIPAA_Share_Phone_1_1HIPAA_Share_Phone_2_1HIPAA_Share_Phone_3_1HIPAA_Share_Name_2HIPAA_Share_Relationship_2HIPAA_Share_Phone_1_2HIPAA_Share_Phone_2_2HIPAA_Share_Phone_3_2HIPAA_Share_Name_3HIPAA_Share_Relationship_3HIPAA_Share_Phone_1_3HIPAA_Share_Phone_2_3HIPAA_Share_Phone_3_3HIPAA_Consent_SignatureHIPAA_Consent_Signature_m010203040506070809101112HIPAA_Consent_Signature_m_txtHIPAA_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031HIPAA_Consent_Signature_d_txtHIPAA_Consent_Signature_y20182019202020212022202320242025202620272028HIPAA_Consent_Signature_y_txtHIPAA_Consent_Relationship 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