IMaJIN Clinic Registration Form 

Use this Clinic Registration Form to give the IMaJIN physicians and Injury Care Coordinators as much information as possible about your medical background.

It is valuable to get specific details of your overall health, including possible drug allergies and present medications. In addition, having a better understanding of any prior health problems and previous surgeries is also valuable. A better idea of previous treatments and investigations will make it easier to give you assistance.

Our goal is to give you the best level of care possible – we appreciate the information!

Open the Clinic Registration Form

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