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
Health Card #
Version Code
Health Card Expiry Date
Address

Street Address

Street Address Line 2

CityProvince / State

Postal / Zip Code
Email
example@example.com
Home Phone Number
Cell Phone Number
Occupation
Please indicate how we can contact you during the day (check all that apply):

Other
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.
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:

Other
Do you have a drug plan:
Have you ever had any of the following diseases or medical problems

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

Other
Authorization
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