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Medical Deferral Request
Medical Deferral Request Last Name of Client First Name of Client Birthdate (YYYY / MM / DD) Personal Health Number (PHN) This form can only be completed by a physician (M.D.) or nurse practitioner. Note: self reports will not be accepted HLTH 2371 2022/03/23 Address Phone Number Signature of Health Care Provider Date Signed (YYYY / MM / DD)
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