form field in header

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I have a medical form template based on MS Word tables, with various fields in each cell. I am using the legacy (Word 2003) format, although I have Windows 7. There are fields stating the patient's name, his date of birth, and the date that the services are needed. If the form extends more than one page, I would like to have this same information automatically repeated on that next page. Is there any way to do this automatically-- in the way that information in the head or footer appears on following pages? More simply put, and form field be put into a header or footer.
 

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