![Maalox / Antacids / Mylanta / Kaopectate Maalox / Antacids / Mylanta / Kaopectate](https://www.pdfsearch.io/img/0f39b8f575a506a5b8dbdabf2b9cd4d4.jpg) Date: 2013-11-12 16:04:36Maalox Antacids Mylanta Kaopectate | | Medical Provider Assessment The following information is required to provide Day Center services for your patient. Name ______________________________M( ) F ( ) Age ______ Date of Birth ___/___/___ Address_______________
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