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  • Cyp Kamloops Clinic Referral Form

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    This document appears to be a patient intake form for a massage therapy clinic located at #306-153 Seymour Street in Kamloops, BC. The form collects information such as the patient's name, diagnosis, special notes, referring doctor's name and billing number, and date. It also lists the clinic director and contact information and allows the patient to indicate their method of payment such as MSP, WCB, ICBC or other.

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    This document appears to be a patient intake form for a massage therapy clinic located at #306-153 Seymour Street in Kamloops, BC. The form collects information such as the patient's name, diagnosis, special notes, referring doctor's name and billing number, and date. It also lists the clinic director and contact information and allows the patient to indicate their method of payment such as MSP, WCB, ICBC or other.

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    © All Rights Reserved
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    38 views1 page

    Cyp Kamloops Clinic Referral Form

    Uploaded by

    api-468186696
    This document appears to be a patient intake form for a massage therapy clinic located at #306-153 Seymour Street in Kamloops, BC. The form collects information such as the patient's name, diagnosis, special notes, referring doctor's name and billing number, and date. It also lists the clinic director and contact information and allows the patient to indicate their method of payment such as MSP, WCB, ICBC or other.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    #306-153 Seymour Street, Kamloops, BC V2C 2C7 / Phone: 778-471-0909 / Fax: 1-844-966-7246

    Melissa West, BPE, RMT - Clinic Director

    MSP __ WCB __ ICBC __ Other __


    Massage __ Work Conditioning __ Other __

    Patient Name: __________________________________________

    Diagnosis: _____________________________________________

    Special Notes:

    Dr. __________________________________________________
    Dr. Billing #: _____________________ Date: ________________

    Educate Restore Movement Improve Quality Of Life

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