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Get Ultrasound Requisition Form 2012-2024

N Toronto, Ontario, Canada M5G 1X6 D 589 (Rev. 05.2012) • A complete and accurate referral MUST be faxed before an appointment will be made. • Doctor’s offices are responsible for notifying the patient of their appointment time and date. Telephone 416-586-8556 Fax 416-586-8405 Patient Demographics Patient name First Last Date of birth Health Card Number VC (YYYY MM DD) Daytime telephone number ( ) Evening telephone number ( ) Appointment Information • Please advise patients.

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