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Please indicate your preferred method of contact. SECTION 1 HEALTH CARE PRACTITIONER INFORMATION First Name s Middle Name if applicable Profession Medical License Number s Province s Licensed in Last Name AB BC MB NB NL NS NT NU ON PE QC SK YT Business Address City Province Postal Code Phone Fax Email Preferred Contact Method for Medical Document Verification phone fax email CONSULTATION ADDRESS The clinic/business address of the location at which the patient consulted with the...
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