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Waterloo Regional Diabetes Education Programs –Central Intake

Newly Diagnosed (less than 1 year) or Established (greater than one year)...Are you pregnant? ...Yes or No If pregnant, when is your due date?...If pregnant, where are you delivering?...Do you...
https://www.wwhealthline.ca/pdfs/Healthy-Living_Community-Diabetes-Program_Self-Referral-Form.pdf

Waterloo Regional Diabetes Education Programs –Central Intake

- Have a confirmed diagnosis of Type 1, Type 2 Diabetes, Prediabetes or at High Risk for Diabetes...- Reside in the Waterloo-Wellington region...Please fill out the following information and send...
https://www.wwhealthline.ca/pdfs/Diabetes_Self_Referral_Form.pdf

ARTHRITIS EDUCATION & REHABILITATION PROGRAM

Alternate Fax Number in the event of transmission problems: 1.613.723.1172 or please call...1.800.321.1433. ext. ...1562...Privacy and Confidentiality: The Arthritis Society has policies...
https://www.wwhealthline.ca/pdfs/Revised-Referral-form-AREP-39-March-2018.pdf

Cardiodiagnostics Services Requisition Form

≤ 1 of 3 3 of 3...Age Male Female Male Female Male Female...30-39 4% 2% 34% 12% 76% 26%...40-49 13% 3% 51% 22% 87% 55%...50-59 20% 7% 65% 33% 93% 73%...60-69...27% 14% 72% 51% 94% 86%...STEP 2.
https://www.wwhealthline.ca/pdfs/Cardiodiagnostics-Services-Requisition-Final-June-2016.pdf

Waterloo Wellington Specialized Geriatric Services Referral Form

Physician Signature: ________________ Date:....,..,,--~--~/=20~- Fax to: 1-888-205-1491...dd mm yyyy...Specialized Geriatric Services You have been referred to these services M...■ D Specialized...
https://www.wwhealthline.ca/pdfs/WW_SGS_ReferralForm_Fillable.pdf