What is the doctor's first name?, Valentino, What is the doctor's last name?, Vega , What is the patient's last name?, Eastwood, What is the patient's date of birth YYYY-MM-DD, 1950-08-08, What screening method does the patient need?, Xray , What will the doctor test from the Xray?, spine , What days is the patient not free?, Thursday and Friday , What province is this requisition form from?, Ontario .

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