eGSR Version 20191006 r1

1. PATIENT INFORMATION




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2. REPRESENTATIVE (TYPE: CAREGIVER, POWER OF ATTORNEY, LEGAL GUARDIAN, REPRESENTATIVE)




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3. QUESTIONS ENTER BELOW OR CONTACT: CLIENT.SERVICES@WHOKNOZME.COM

BC Health FOI Service Requests

Health Record Retrieval

Customer Service Requests

4. AUTHORIZATON – TO BE SIGNED BY THE PATIENT OR REPRESENTATIVE

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