New Patient Intake Form

New Patient Intake Form

**Please note: Filling out this form DOES NOT mean you have been accepted as our patient, but we will put you into our patient intake waiting list. Once received and reviewed, we will be in contact to book your meet and greet appointment. Unfortunately We will not be able to give out a estimated waiting time
Patient Name*

First NameLast Name
Care Card Number*
Email Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Biological Gender

FemaleMale
Country of Birth*
Primary Contact Number*
Secondary Contact Number (optional)
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Relationship
Current Medical Conditions
List any current medical conditions that apply to you
Are you currently taking prescription medication?*

YesNo
What are the prescription medications you are taking?
Allergies (include the trigger and the reaction you get, e.g. penicillin - rash, peanuts - hives):
Do you have a previous family doctor in Canada?*

NoYes (Please specify his/her contact information)
Other information you want the doctor to know:
**Please note: Filling out this form DOES NOT mean you have been accepted as our patient, but we will put you into our patient intake waiting list. Forms will be processed on a first come first served basis. Once received and reviewed, we will be in contact to book your meet and greet appointment.
Should be Empty:

Emergency Contact Information