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CONFIDENTIAL
Page 1 of 6
UR NUMBER
SURNAME
GIVEN NAME(S)
DATE OF BIRTH
AFFIX PATIENT LABEL HERE
LeftRight
Date / / Time : Signature of assessing doctor
Victorian Forensic Paediatric
Medical Service
Body chart child
*FRC950470*
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To think is easy. To act is difficult. To act as one thinks is the most difficult. | Johann Wolfgang Von Goeth