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Get Dysphagia System Disorder Template

Site Outpatient Dysphagia Clinic Referral Form Peter Lougheed Centre 3500 - 26th Avenue NE Calgary AB T1Y 6J4 Phone 403-943-4941 Fax 403-943-4520 Patient Contact Information Phone Fax Does this patient have a legal guardian Yes No If Yes Language Medical History relevant to swallowing problem Pulmonary / Respiratory status Neurological diagnosis Cancer Treated with radiation Other Medications History/Duration of Swallowing Problem/Reason for Ref.

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