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Name

First

Last

Health Card #

WSIB # (if active)

Date of Birth

Gender

Height

cm

Weight

lbs

Home Address

City

Province

Postal

Email

Phone

Family Doctor

Dr.

Phone

Fax

Referring Physician

Dr.

Phone

Fax

Pharmacy

Phone

Fax

When and how did your current pain problem start?

Has your pain changed since it began?

Have you visited the emergency room for your pain in the past 12 months?

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Upload any medical documents or images you may have.

Maximum file size: 25MB