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Diabetic Senior

Website

Your Full Name

Email

Phone (10 digits)

Type Mobile Home Office Other

Date of Birth (optional)

Age on appointment date:

Comments (optional)

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Do you have Diabetes and/or Glaucoma, and/or take: hydroxychloroquine, chloroquine, tamoxifen, or ethambutol?Select…YesNo

What will your age be on the date of your exam?

Do you currently have coverage through Indigenous Services, ODSP, or OW?Select…NoIndigenousODSPOW

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