Lifecure – Generic Episodic Care Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Email
example@example.com
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Sex at Birth
Female
Male
Intersex
Prefer not to say
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
OHIP / Health Card Number
7
Date of Visit
Date
Month
Day
Year
8
Email* This field is required.
example@example.com
9
Phone Number* This field is required.
Please enter a valid phone number.
10
Preferred Pharmacy Name
11
Pharmacy Address
12
Pharmacy Phone
Please enter a valid phone number.
13
Pharmacy Fax
14
Medication Coverage
ODB (Government)
Trillium Drug Plan
None
Private Insurance
15
Provider Name* This field is required.
16
Carrier ID* This field is required.
17
Client ID* This field is required.
18
Group Number* This field is required.
19
Insurance Card Upload (optional)
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20
What brings you in today?* This field is required.
21
When did this start and how has it changed over time?
22
Describe symptoms including location, severity, frequency, triggers, and what improves or worsens.
23
How is this affecting your daily life (sleep, work, activities)?
24
Have you tried anything so far? Did it help?
25
Any relevant medical history related to this concern?
26
Current medications
27
Medication allergies?
Yes
No
28
List medication and reaction* This field is required.
29
New medications recently?
Yes
No
30
Blood thinners?
Yes
No
31
Do you have any of the following urgent symptoms?
Chest pain or shortness of breath
Severe or rapidly worsening pain
New weakness, numbness, or confusion
Fever with feeling very unwell
Persistent vomiting or bleeding
32
Pregnant or possibly pregnant?
Yes
No
33
Breastfeeding?
Yes
No
34
Immune suppression conditions
HIV
Cancer
Organ transplant
Lupus
Splenectomy
None
35
Immune suppression medications
Steroids
Chemotherapy
Biologics
None
36
Is there anything else we should know?
37
Upload bloodwork if available (PDF, JPG, PNG)
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Select files to upload
Max. file size: 10.0MB
Upload a File
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38
I confirm the information I provided is accurate.* This field is required.
39
I consent to being contacted by Lifecure.* This field is required.
40
Preferred contact method
Phone
Email
Text
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