New Patient Form

Appointment

Patient Intake Form

Name

Gender

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Date of Birth

Manitoba Health PHIN #

Phone Number*

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Preferred Pharmacy

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Name

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Medical History

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Date

We’re excited to welcome Dr. Banafsheh Salimarouny to Astro Medical! Starting May, Dr. Salimarouny is accepting new patients — no waitlist. Book your appointment online or call our clinic today.