New Patient Registration Form

New Patient Registration Form
Name*

First NameLast Name
I prefer to be called :
(name)
Date of Birth

MonthDayYear
Date
Age
Sex

MaleFemaleN/A
Health Card #
Version Code
Health Card Expiry Date
Address*

Street Address

Street Address Line 2

CityProvince / State

Postal / Zip Code
Email*
example@example.com
YES! I would like to receive promotional emails or invitations to special events at Dermatology On Bloor.
Home Phone Number*
Cell Phone Number
Occupation
Please indicate how we can contact you during the day (check all that apply):

EmailHomeCellOther
Whom may we thank for referring you?
Referring Doctor/Family Doctor:
Guardian or power of attorney (if applicable) :
If patient 16yrs or younger, does not speak English, or lack capacity, please provide guardian's info:
Home Phone Number
Cell Phone Number
I authorize Derm On Bloor to communicate with my Guardian on my behalf.

Yes
Patient's Signature :
(Your digital signature (full name) is as legally binding as a physical signature.)
Medical History
Current Medications: (prescription, over the counter, vitamins, etc.)
Past Surgeries:
Medical Conditions:
Allergies to Medications, Foods etc:
Do you take Aspirin or blood thinners:

YesNoOther
Do you have a drug plan:

YesNo
Have you ever had any of the following diseases or medical problems

AsthmaHay feverEczemaPsoriasisBasal Cell CarcinomaSquamous Cell Skin CancerMelanomaOther Skin CancerOther CancerDiabetesHigh Blood PressureHigh CholesterolLiverKidneyLungHeart DiseaseLupusRheumatoid ArthritisMultiple SclerosisCrohn's DiseaseUlcerative ColitisThyroid DiseaseVitiligoAlopecia AreataDepressionHeadachesSeizuresEyesEarsNoseMouthBlood ClotsBleeding DisordersOther
Please explain:
Family History:
Please list any diseases that run in your family:
Does anyone in your family have the following (if so, please indicate who):
Social History :
Do you smoke?

YesNo
How many times per day?
Do you use sunscreens?

YesNo
What SPF and which months?
How much alcohol do you drink?
Are you pregnant or planning to become pregnant?
Skin Care Routine :
How often do you shampoo?
How often do you bathe/shower?
How often do you wash your face?
What moisturizers do you use?
Questions About Our Practice
How did you hear of our practice?
If other, please describe
Please check any of our COSMETIC DERMATOLOGY services about which you would like to learn more

Skin Care ProductsGlycolic Peels / MicrodermabrasionLaser Hair RemovalBotoxTMEliminating Facial/Acne ScarsFacial Skin TighteningLaser Tattoo RemovalEliminating Leg VeinsBotoxTM for Excessive SweatingRemoval of Moles/Skin Tags/CystsReducing Wrinkles or crepe-paper-like skinPhoto-Rejuvenation (Improve Skin Tone/Texture/Colour/Pore size)Body Skin TighteningRestylane/PerlaneJuvederm/VolumaRadiesseSculptraSelphylOther
Authorization*

I authorize my physician to release medical information concerning my visit to the referring physicians. In some instances your care may be provided by another physician in the office.
Signature :*
(Your digital signature (full name) is as legally binding as a physical signature.)
Date*

MonthDayYear
Should be Empty:

New Patient Registration Form

Medical History