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Fillable Online q SCAN ONLYNo additional information needed Fax Email 2026
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- Click ‘Get Form’ to open it in the editor.
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- Fill in the patient’s name, date of birth (DOB), OHIP number, email, and phone number in the designated fields.
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- In the 'Past Medical History' section, indicate if the patient is healthy or list any other conditions as necessary.
- For medications, specify any prescription medications or note 'None' if applicable.
- Document any allergies in the allergies section; if there are none, write 'None'.
- Finally, sign and date at the bottom of the form to validate your referral.
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Scan and email it to MSHAs Office of Injury and Employment Operations (OIEI) or FAX to 888-231-5515 or mail it to: PEIR-Office of Injury and EmploymentRead more
Oct 1, 2025 Additional information enclosed. Phone: (209) 575-6968 Fax: (209) 575-6969. You may copy this form if additional space is needed. Contact YCCD