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REFERRAL FORM 2230 Osborne St. R3L 1Z5 Winnipeg, MB pH: (204) 8181564 Fax: (204) 4107090PATIENT DEMOGRAPHICS Gender:Name: Address: MHSC (6Digit):PAIN (9Digit):Email:Date of Birth:(Home):Phone: (Work)(Cell):REASON
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Start by writing the recipient's name on the first line.
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Indicate the house or building number on the second line (in this case, 2-230).
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Write 'Osborne St' on the third line to specify the street name.
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