Registration Form

Registration Form

ENT Vancouver
I am a

New patient with a booked appointmentNew patient without a booked appointmentReturning patient with new information
This registration form is only for patients with a booked appointment.

We are currently accepting referrals. Please note appointments covered by BC MSP may only be booked by referral from a licensed physician. Please contact your Family Doctor or visit your nearest walk-in clinic and/or UPCC.
- Name (full legal)
  
  First nameFamily name/Surname
- MaleFemaleOther
- Date of birth
  
  MonthDayYear
  Date
- Care Card (PHN)
  Indicate the province/territory if not BC
- Address
- City
- Postal Code
- Daytime phone #1
- Daytime phone #2
- Email
  example@example.com
- Permission to contact by email?
  
  YESNO
- Alternate contact name & phone
- Family physician
- Referring physician
- Occupation
- Employer
- Reason for your visit
- Height
- Weight
- Medical History (please check)
  
  diabetesbad scarringhepatitisanemia/bleeding disorderHIVobstructive sleep apneahigh blood pressuredifficulty with anestheticheart diseaseautoimmune disorderhead injury/seizuresradiation therapyacid refluxasthma/COPDkidney diseasecancerOther
- Past surgery
- Medications
- Allergies (drug/other)
- Smoking history: Number of packs per day for number years.
- Currently smoking?
  
  YESNO
- Smoking Quit Date
  
  MonthDayYear
  Date
- Alcoholic drinks per day
- Should be Empty: