BRGY.
__9_____
MONTH OF _AUGUST 2023___
BIRTH
SEX
FULL NAME CONTACT DATE AG DATE
DATE STREET (M/ SIGNS & SYMPTOMS ADVISE/TREATMENT GIVEN
(First, Middle Name, Last Name) NO. (MM-DD- E ONSET
F)
YYYY)
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BRGY. __9_____
MONTH OF _AUGUST 2023___