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Physical therapy referral

An eform for referring to physio, massage or chiropractic. Contributed by Jel Coward.

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<H1>Pemberton Medical Clinic</H1>

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<input type="checkbox" name="C1" value="ON">Dr. Hugh Fisher 03877<br>
<input type="checkbox" name="C2" value="ON">Dr. Rebecca Lindley 26399<br>
<input type="checkbox" name="C3" value="ON">Dr. Marisa Collins 07067<br>
<input type="checkbox" name="C4" value="ON">Dr. Jel Coward 27015
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    <td width="50%" valign="top" align="right">Box 69, Pemberton, B.C. V0N 2L0 <br>
Phone 604-894-6454<br>
      Fax
604-894-6721
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REFERRAL FOR:<br><br>
<input type="checkbox" name="C5" value="ON">Physiotherapy<br><br>
<input type="checkbox" name="C6" value="ON">Massage<br><br>
<input type="checkbox" name="C7" value="ON">Chiropractic<br></p>

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<p class="small"> At the Pemberton Medical Clinic, we value the relationship we have with our local allied health care practitioners and are happy to refer our patients for care. We recognize that in the course of treatment, different symptoms or signs may present. We request that if you believe a patient could benefit from additional investigations, referrals, etc. you please send them back to our office for reassessment and further management.
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<p class="bold">Signed:</p> 

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