Health History Form Health History Form 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 * Male Female Address * Address Address Address City City State/Province State/Province Zip/Postal 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 Next If you are human, leave this field blank.
