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Please complete and send to Victoria General Hospital 2340 Pembina Hwy Winnipeg MB R3T 2E8 Phone 204 477-3540 Fax 204 477-3299 Physician Information please use stamp Patient Information Patient Name MHSC PHIN Date of Birth Age Gender Male Female Address Phone No. Home Alt. Has the patient had Bariatric weight loss surgery liposuction or upper G.I surgery 6. Is the patient ambulatory and able to perform ADL s 7. Smoke this includes all inhalants and E cigarettes Quit date 2. Have alcohol and...

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