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Patient Intake Form
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Patient Intake Form
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Manitoba Health PHIN #
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Medical History
Current Medications:
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Appointment
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Date
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First Name
Last Name
MB REG#
PHIN#
D.O.B
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Do You Presently Have A Family Doctor?
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If Yes, Who Is Your Family Doctor? (Optional)
List Allergies If Applicable
Do You Use Narcotics Regularly? (Ex. Morphine, Percocet, T3)
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List Of Medications
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