Health History Update Form Health History Update Form Welcome to Edmonton Dermatology & Skin Surgery Centre, the office of Dr. Muba Taher and Associates. We request one of these forms is filled out every 6 months. Please complete the ENTIRE 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 * 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.