Dermatology Center of Washington Township
Child’s Name: DOB: Sex: Case Number: SWSS Log No.: Address: Medicaid Recipient ID #: Caseworker: Caseworker Telephone No.: BIRTH INFORMATION Prenatal Care: Yes No Unknown Full Term Pregnancy: Yes No Unknown Birth Weight: Gestational Age: Type of Delivery: Natural Cesarean Prenatal exposure to alcohol or other controlled substances Yes … ................
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