New Patient Form

Simon Fraser Medical Centre - New Patient Application Please email to: natasha@polycanhealthcentre.com

To book appointments, please email above or TEXT 604 260 4040

How did you hear about our clinic?

Friend/ FamilySFUDirect physician referralOther

First Name

Last Name

Personal Health Number

Date of Birth YYYYMMDD

Date

Address

City

Postal Code

Home Phone

Cell Phone

Work Phone

Email

example@example.com

Gender

Emergency Contact - Name

Number

Relation

Preferred Pharmacy

Previous Doctor

Previous Doctor Contact Information

Preferred Lab

Do you have any ICBC or WCB Claims?

YesNoOther

Current Weight

Current Height

Current Diseases

Current Symptoms

Allergies

Do you currently smoke? If you have quit but have history, please indicate below. Please also indicate when you started living in a smoking environment and if you still currently are.

Surgical History

Past Diseases

Medications

Non Prescription Medications

History with substance abuse

How much alcohol do you consume per week?