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Get Canada IMM 5734 E 2019-2024

YY-MM-DD): Identity document seen? No Yes Document type: Passport Government issued photo ID If you have any concerns that the individual presenting to you does not match the identification and photo of the individual above, please notify my office immediately. Referred to (Specialist name / address): Referred by (Panel Physician name / address): Reason for referral: Report to include: Clinical findings with current clinical status; Diagnosis; Pathology report if available;.

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