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Atrial Fibrillation Clinic Name Royal Jubilee Hospital 1952 Bay Street Royal Block 3rd Floor Rm 343 Victoria B.C. V8R 1J8 Phone 250-370-8632 FAX NUMBER 250-595-1000 via Western Cardiology DOB M/F PHN MRN Address Telephone number REFERRAL FORM PLEASE NOTE ECG DOCUMENTATION OF AF IS REQUIRED Date Referring physician/NP please print Total pages Referred from Primary care Internist ED Other Please provide the following history AF diagnosis Check o.

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