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First Name:

Last Name:

Date of Birth: (mm/dd/yyyy)

Telephone Number:

Email:

Home Address:

City:

Province: (Only for Canada)

Country:

Postal Code:

Personal Health Care Number (Care Card):

Area Needed To Scan:

Area Needed To Scan (2nd):

Other:

Preferred Appointment Date:

Preferred Appointment Time:


Please fax (604-734-2469) or email your physician referral to us info@aimmedicalimaging.com.

Or, upload here

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Thank you for choosing AIM Medical Imaging.