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一般信息您是向我们的办公室转介吗？是，如果是，我们可以感谢谁转介？_________________________ Phone: _____________ Address: __________________________________________________________________________ Child's Full Name: __________________________________________________ Male/ Female Birth Date: _________________________ Age: _____ years ______ months Name of School: __________________________________________ Grade: ________ Teacher: _______________________校长：________________________________您的孩子特别害怕医生吗？_________________________________________ Child's dominant hand (circle): right or left ?是否有使用手的指导？Yes No Father's Name: _________________________ Mother's Name:______________________________ Daytime Phone:__________________________ Evening Phone:_______________________________ Cell Number:_____________________________________ Email Address:____________________________________________________________
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