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Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples

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Page 1: Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples
Page 2: Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples
Page 3: Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples
Page 4: Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples
Page 5: Ching Healthcare Institute - Home · Caffeine Use: Yes or No Coffee Tea Energy drink Sodas ... ACKNOWLEDGMENT FORM NAME OF PATIENT (please print clearly) Date of Birth ... samples