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Newborn Registration

Date: 

1) Infant's first name:   Last:

2) Medical Record #:

3) Date of birth:

4) Birth weight :

5) APGAR score :

6) Mother's first name: Last: 

7) Father's first name : Last:  

8) Physician (check all that apply:)

Dr.Warren Albert Dr.Maren Alvarez Dr.Karen Brinkman Dr.Michael Kerry Dr.Chad Nichols Dr.Karn Paulson Dr Tai Webb