Confidential Patient Information...Kidney trouble Kidney stone Bloody urine Frequent urination...

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650EastDevonAve,Suite152Itasca,IL60143

ConfidentialPatientInformation

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Ethnicity_____________________Height(inches):___________ Weight(pounds):________DateofBirth(mm/dd/yy): ______________ Age:_________ Gender:M/FHowdidyouhearaboutus?_____________________________________________________________EmergencyContactName:_____________________________________ Phone:____________________________________

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