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D to Renfrew County & District Health Unit per the Ontario Health Protection and Promotion Act. Please complete and return by mail, courier (address below) or fax to Clinical Services Coordinator at Fax: (613) 735-3067. (Please Print) Patient Information Surname: First Name: DOB: Gender: M F Phone: (H) (W) y / m / d Address: Mantoux: Date given: Date read: y / m / d Results: mm y / m / d CXR: Results: y / m / d Sputum smear(s) if Respiratory symptoms: Results: y / m / d.

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