Health History Form - Edmonton Dermatology & Skin Surgery Centre

Welcome to Edmonton Dermatology & Skin Surgery Centre, the office of Dr. Muba Taher and Associates. Please complete this form and sign. Please know that all this information is kept private and confidential.

Downloadable Form Here

Legal First & Last Name *

Preferred First Name *

Date of Birth *

Gender *

Address *

Address

City

State/Province

Zip/Postal

Alternate Phone

Primary Phone *

Email *

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Alberta Health Care Number *

Physician Information

Referring Physician First & Last Name

Primary Care Physician First & Last Name

Primary Care Physician Location

Pharmacy Name

Pharmacy Location

Pharmacy Phone Number