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PIN OR J#: ___ NAME: ___ Last First ADDRESS: ___VICTORIA HOSPITAL URGENT MEDICINE CLINIC: ED CONSULTS / REFERRALS ***Urgent Consults only***___ BIRTHDATE: ___ YYY/MM/TELEPHONE: ___OH#:___ VERY. CODE:

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The statement from secretary of must typically include the date, subject, background information, discussion points, decisions made, and any action items or follow-up steps.

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