(805) 303-4507 Simi Valley, CA

Beatty & Associates Insurance Agency

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Tobacco Use?
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Child 1

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Child 2

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Child 3

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Use Tobacco
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Gender
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Date of Birth

Height

Weight

List medications and reasons

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Beatty & Associates Insurance Agency | 940 Enchanted Way, Suite 102 | Simi Valley, CA 93065 | (805) 303-4507

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