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Urology Central Intake Referral
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Urology Central Intake Referral - Alberta Health Services
www.albertahealthservices.caUrology Central Intake Referral Name (last fi rst) PHN / HRN Phone Address Gender Date of Birth (yyyy-Mon-dd) Requested Provider Emergency Department Only Appropriate provider assigned by intake protocol Specifi c surgeon or clinic/previous urologist Name _____ Comments _____ ...