"*" indicates required fields 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: SexMFAge Marital Status:MinorSingleMarriedLong-Term PartnerDivorcedWidowedSeparatedDate of Birth: Month010203040506070809101112Day01020304050607080910111213141516171819202122232425262728293031Year20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Social Security # Drivers License StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYDrivers License # Home Phone* Work Phone Cell Phone Email Address Home Address: City: State:ALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYZIP: Employment Status:NoneFull-TimePart-TimeRetiredEmployer's Name Employer's Phone: Occupation: Employer's Address City: State:ALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYZIP: Student_StatusNot a StudentFull-TimePart-TimeStudent_Status_txt School_Name Grade Best_Contact Reminder_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_text How_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_text How_Found11 First Choice Second Choice Third Choice How_Found11_text website_factor website_factor website_factor Spouse_Parent_Name Spouse_Parent_Employer_Name Spouse_Parent_Work_Phone_1 Spouse_Parent_Work_Phone_2 Spouse_Parent_Work_Phone_3 Spouse_Parent_Cell_Phone_1 Spouse_Parent_Cell_Phone_2 Spouse_Parent_Cell_Phone_3 Additional_Family_Members Comments Emergency_Contact_TitleMr.Ms.Mrs.Dr.Emergency_Contact_Title_txt Emergency_Contact_First_Name Emergency_Contact_Last_Name Emergency_Contact_Relationship Emergency_Contact_Phone_Home_1 Emergency_Contact_Phone_Home_2 Emergency_Contact_Phone_Home_3 Emergency_Contact_Phone_Work_1 Emergency_Contact_Phone_Work_2 Emergency_Contact_Phone_Work_3 Emergency_Contact_Phone_Cell_1 Emergency_Contact_Phone_Cell_2 Emergency_Contact_Phone_Cell_3 Emergency_Contact_Email Emergency_Contact_Address Emergency_Contact_City Emergency_Contact_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYEmergency_Contact_State_txt Emergency_Contact_ZIP Responsible_Person_TitleMr.Ms.Mrs.Dr.Responsible_Person_Title_txt Responsible_Person_First_Name Responsible_Person_Middle_Name Responsible_Person_Last_Name Responsible_Person_Relationship Responsible_Person_DOB_m010203040506070809101112Responsible_Person_DOB_m_txt Responsible_Person_DOB_d01020304050607080910111213141516171819202122232425262728293031Responsible_Person_DOB_d_txt Responsible_Person_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Responsible_Person_DOB_y_txt Responsible_Person_SSN_1 Responsible_Person_SSN_2 Responsible_Person_SSN_3 Responsible_Person_DL_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYResponsible_Person_DL_State_txt Responsible_Person_DL_Number Responsible_Person_InsuranceNoYes: Primary Insurance PolicyYes: Secondary Insurance PolicyResponsible_Person_Insurance_txt Responsible_Person_Phone_Home_1 Responsible_Person_Phone_Home_2 Responsible_Person_Phone_Home_3 Responsible_Person_Phone_Work_1 Responsible_Person_Phone_Work_2 Responsible_Person_Phone_Work_3 Responsible_Person_Phone_Cell_1 Responsible_Person_Phone_Cell_2 Responsible_Person_Phone_Cell_3 Responsible_Person_Email Billing_Address Billing_City Billing_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYBilling_State_txt Billing_ZIP Responsible_Person_Employment_StatusNoneFull-TimePart-TimeRetiredResponsible_Person_Employment_Status_txt Responsible_Person_Employer_Name Responsible_Person_Phone_Employer_1 Responsible_Person_Phone_Employer_2 Responsible_Person_Phone_Employer_3 Responsible_Person_Occupation Responsible_Person_Work_Address Responsible_Person_Work_City Responsible_Person_Work_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYResponsible_Person_Work_State_txt Responsible_Person_Work_ZIP Primary_Insurance_Name Primary_Insurance_DOB_m010203040506070809101112Primary_Insurance_DOB_m_txt Primary_Insurance_DOB_d01020304050607080910111213141516171819202122232425262728293031Primary_Insurance_DOB_d_txt Primary_Insurance_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Primary_Insurance_DOB_y_txt Primary_Insurance_Relationship Primary_Insurance_Employer Primary_Insurance_Member_ID Primary_Insurance_Group_ID Primary_Insurance_Company_Name Primary_Insurance_Phone_1 Primary_Insurance_Phone_2 Primary_Insurance_Phone_3 Primary_Insurance_SSN Primary_Insurance_Address Primary_Insurance_City Primary_Insurance_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYPrimary_Insurance_State_txt Primary_Insurance_ZIP Secondary_Insurance_Name Secondary_Insurance_DOB_m010203040506070809101112Secondary_Insurance_DOB_m_txt Secondary_Insurance_DOB_d01020304050607080910111213141516171819202122232425262728293031Secondary_Insurance_DOB_d_txt Secondary_Insurance_DOB_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886Secondary_Insurance_DOB_y_txt Secondary_Insurance_Relationship Secondary_Insurance_Employer Secondary_Insurance_Member_ID Secondary_Insurance_Group_ID Secondary_Insurance_Company_Name Secondary_Insurance_Phone_1 Secondary_Insurance_Phone_2 Secondary_Insurance_Phone_3 Secondary_Insurance_SSN Secondary_Insurance_Address Secondary_Insurance_City Secondary_Insurance_StateALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYSecondary_Insurance_State_txt Secondary_Insurance_ZIP Insurance_Consent_Signature Insurance_Consent_Signature_m010203040506070809101112Insurance_Consent_Signature_m_txt Insurance_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031Insurance_Consent_Signature_d_txt Insurance_Consent_Signature_y20182019202020212022202320242025202620272028Insurance_Consent_Signature_y_txt Patient_Name_Consent Treatment_Consent_Signature Treatment_Consent_Signature_m010203040506070809101112Treatment_Consent_Signature_m_txt Treatment_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031Treatment_Consent_Signature_d_txt Treatment_Consent_Signature_y20182019202020212022202320242025202620272028Treatment_Consent_Signature_y_txt Patient_Name_Payment Payment_Policies_Signature Payment_Policies_Signature_m010203040506070809101112Payment_Policies_Signature_m_txt Payment_Policies_Signature_d01020304050607080910111213141516171819202122232425262728293031Payment_Policies_Signature_d_txt Payment_Policies_Signature_y20182019202020212022202320242025202620272028Payment_Policies_Signature_y_txt general_health general_health general_health general_health current_treatmentYesNocurrent_treatment_txt current_treatment_details antibiotic_premedicationYesNoantibiotic_premedication_txt antibiotic_premedication_details physician_Name physician_Phone_1 physician_Phone_2 physician_Phone_3 physician_Last_Visit_m010203040506070809101112physician_Last_Visit_m_txt physician_Last_Visit_y20282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886physician_Last_Visit_y_txt contact_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_txt cancer_details bisphosphonate_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_text female_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_List Serious_Conditions Medical_History_Signature Medical_History_Signature_m010203040506070809101112Medical_History_Signature_m_txt Medical_History_Signature_d01020304050607080910111213141516171819202122232425262728293031Medical_History_Signature_d_txt Medical_History_Signature_y20182019202020212022202320242025202620272028Medical_History_Signature_y_txt Reviewed_By Reviewed_By_Title Reviewed_m010203040506070809101112Reviewed_m_txt Reviewed_d01020304050607080910111213141516171819202122232425262728293031Reviewed_d_txt Reviewed_y20182019202020212022202320242025202620272028Reviewed_y_txt HIPAA_Share_Name_1 HIPAA_Share_Relationship_1 HIPAA_Share_Phone_1_1 HIPAA_Share_Phone_2_1 HIPAA_Share_Phone_3_1 HIPAA_Share_Name_2 HIPAA_Share_Relationship_2 HIPAA_Share_Phone_1_2 HIPAA_Share_Phone_2_2 HIPAA_Share_Phone_3_2 HIPAA_Share_Name_3 HIPAA_Share_Relationship_3 HIPAA_Share_Phone_1_3 HIPAA_Share_Phone_2_3 HIPAA_Share_Phone_3_3 HIPAA_Consent_Signature HIPAA_Consent_Signature_m010203040506070809101112HIPAA_Consent_Signature_m_txt HIPAA_Consent_Signature_d01020304050607080910111213141516171819202122232425262728293031HIPAA_Consent_Signature_d_txt HIPAA_Consent_Signature_y20182019202020212022202320242025202620272028HIPAA_Consent_Signature_y_txt HIPAA_Consent_Relationship EmailThis field is for validation purposes and should be left unchanged. 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