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Get Occupational Health Referral

F any safety concerns for the clinician entering this client s home environment: Yes No If yes, what are they? Please indicate if the following applies: 50 years of age and above: Yes No Not referred to or receiving CCAC OT services: Yes No Has had a fall or is at risk of falling: Yes No Client is considered in the lower socio-economical range: Yes No Page 1 of 2 *Local Community Health Centres Phone & Fax Numbers on Page 2 Program Contac.

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