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Click ‘Get Form’ to open it in the editor.
Begin with Part I: Identification Information. Fill in your first name, middle name, last name, address, city/town, province, postal code, email address, and telephone numbers. Ensure all details are accurate for effective communication.
Proceed to indicate your date of birth and marital status. Select your sex and provide your health care number along with emergency contact details.
In Part II: Referral Information, if applicable, enter the name of the referral agency and their contact information. Provide details of any previous treatment for addictions.
Move on to Part III: Health, Medical and Legal Information. Answer questions regarding medications you are taking and any health concerns you may have. Be thorough as this information is crucial for your treatment.
Continue through Parts IV to VI by providing information about your alcohol/drug history, tobacco use, and financial arrangements for treatment. Make sure to review each section carefully before submission.
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Print the health clearance form and complete the top portion prior to your appointment. For in-person visits, take the form(s) with you to your appointment.
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