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Patient information

First name

Last name

Date of birth (YYYY-MM-DD)

Email

Phone #

Health card # (AAAA 0000 0000)

Address

City

Postal code (A0A 0A0)

Reason for consultation

Where has the pain/symptoms been the worse?

Arm

Back

Leg

Neck

Consult notes (optional)

Send consult notes to my family physician after my CareAxis assessment.

Yes

Family physician

First name

Last name

Phone #

Extension #

Fax #

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