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Get Canada PANL Medication Review Form For Patient With Diabetes 2017-2024

Ug Name Reaction Drug Name Reaction MCP Number: Family Physician Information Medical Conditions/Lifestyle Yes Name Phone Number Fax Number No List all known medical conditions: Contacted Patient Use of Tobacco Products Patient Use of Alcohol Patient Consent Information Consent Given by Patient Consent Given by Patient Representative (name): Patient Physical Activity Best Possible Medication List (Including Rx, OTC and Natural Products) Drug Name and Strength Dosage Reas.

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