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ROTHESAY
MEDICAL CLINIC
PRIMARY HEALTHCARE
Fill out this new patient form
Please complete this form to apply for a family doctor. If you would like to speak with us on the phone, do not hesitate to call us at:
204-808-4222
Choose your preferred clinic location
*
Rothesay
Ness
First name
*
Last name
*
Email
Phone (Cell)
*
Phone (Home)
Can we leave messages for you
Yes
No
Birthday
Year
Month
Month
Day
Multi-line address
Country/Region
Address
City
Zip / Postal code
Gender
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