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Get OTs 2 Go Screening Form - Hamilton Health Sciences

Iver Family Physician: Cell Phone Diagnosis: Day Program: Attendance Days: Type of Mobility Device Currently in Use: Condition of Device Referred by Safety at Home Mobility Assessment Home Safety (Hamilton Residents Only) Rationale for Referral Referred By: Phone/ext. Date of receipt: Fax to: 905-549-5080 Phone: (905) 777-3837 ext. 12424.

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