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CH-0039(Rev2015-10) Complete patient information on reverse

Complete patient information on reverse - Home | Alberta ... · Box A — Patient History Asymptomatic Antimicrobial / Antiviral in use Recent travel (country) Box B - Rubella Serology

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Page 1: Complete patient information on reverse - Home | Alberta ... · Box A — Patient History Asymptomatic Antimicrobial / Antiviral in use Recent travel (country) Box B - Rubella Serology

CH-0039(Rev2015-10) Complete patient information on reverse

Page 2: Complete patient information on reverse - Home | Alberta ... · Box A — Patient History Asymptomatic Antimicrobial / Antiviral in use Recent travel (country) Box B - Rubella Serology

CH-0039(Rev2015-10)

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