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Telemedicine Referral Form- revised dec 2018.pdf
Nousheen Kanji...If problems faxing please contact Belleville & Quinte West CHC @ 613-962-0000 x 258 Dec 2023...161 Bridge St. ...West, Belleville ON K8P 1K2 613-962-0000 69 Catherine St Trenton K8V 5K9...
https://www.southeasthealthline.ca/pdfs/Telemedicine%20Referral%20Form-%20revised%20dec%202018.pdf
“APPLICATION TO REGISTER” For Health Services
Name of your preferred
pharmacy
: _____________________Telephone#________________...Location: ____________________________________________...Prescribed Medication Dosage How Often?...1...2...3...4
https://www.southeasthealthline.ca/pdfs/BQWCHC_application_referral_form_oral_Health_Services.pdf
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