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Uptown Eye Specialists Referral Form
CONSULTATION
REQUEST
FORM
Referring
Doctor:
_______________________________________
OHIP
Billing
#:
_________________________________________
Office
Phone:
___________________
Fax:
__________________
Patient
Last
Name:
_____________________________________
Fariba Nazemi, MD FRCSC
Eye Physician and Surgeon
Strabismus and Cataract Surgery
Pediatric Ophthalmology
First
Name:
___________________________________________
...
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