a 20) 9 g3 M s alemple e %tarried o Divorced a widowed o Sainted a Planer ()Other Ethnicity I prelerred Language et4CL-I SI-, Country of Unpin LA SA I Name a-. i t 1 2 Is patient responsible patina:want& Meal:Nal( you are the person financially raporutble for sty charges you are orr Ow age o