J-Von Medical Clinic Policy Agreement & New Patient Registration(CN&EN)

Please read this information before you continue(请确认您已阅读以下条款)*

Please enter English, please do not enter any Chinese character. Type N/A if an item is not applicable.请输入英文，请不要输入中文。请写N/A，如果这个问题不是适用于您。

PERSONAL INFORMATION 个人信息

Patient Name 病人姓名 (Please make sure yourname match with your Care Card,请确定您所输入的名字和医疗卡上面的名字是一致的)*

First Name 名字Last Name 姓氏

Date of Birth 出生日期*

Month-Date-Year 月-日-年

Gender 性别*

Male 男性Female 女性

Personal Health Number (PHN) 医疗卡号码 (Please make sure the numbers you entered matching with your care card numbers,您填写的卡号请务必和医疗卡号匹配)*

Address 地址（must include unit number,请提供门牌号）*

Street Address Line 1 地址栏1

Street Address Line 2 地址栏2

City 城市state / province 洲 / 省份

Postal / Zip Code 邮政编码

Primary Phone 首要联系电话（if this phone can not leave voice mail please provide second number,如果这个号码无法留言请务必提供其他可留言号码）*

Secondary Phone 第二联系电话（can be home phone, work phone请提供家里或者单位电话）*

Contact Email 电子邮箱*

example@example.com

Emergency Contact Name 紧急联系电话*

First Name 名字Last Name 姓氏

Emergency Contact Number 紧急联系人电话*

MEDICAL HISTORY 医疗历史

Type N/A if an item is not applicable.
请写N/A，如果这个问题不是适用于您。

Past Medical Issues 过往病史*

Previous Family Doctor's Name 以前家庭医生的名字*

First NameLast Name

Surgeries You Had 以前做过的重大手术*

Specialists You Saw Before 以前看过的专科医生*

Medication You Take (& dosing) 目前吃什么药物*

LIFESTYLE 生活方式

Type N/A if an item is not applicable.
请写N/A，如果这个问题不是适用于您。

Caffeine how much/day 每天喝多少杯咖啡*

Tobacco how much/day 每天抽多少根香烟*

Alcohol how much/day 每天喝多少杯酒*

Sleep how many hours 每天睡眠多少小时*

Allergies 有对什么过敏吗?*

MEDICAL TEST HISTORY 医疗测试历史

Stool test for blood 是否进行过大便样本测试*

YesNo

Tested date

Month-Date-Year

Colonoscopy 是否进行过肠镜或胃镜*

YesNo

Tested date

Month-Date-Year

Mammograms 是否进行过乳房检查*

YesNo

Tested date

Month-Date-Year

Pap smears 是否进行过妇科检查或宫颈抹片*

YesNo

Tested date

Month-Date-Year

Do you use recreational substances 您是否进行娱乐性用药？*

YesNo

Tested date

Month-Date-Year

OTHER INFORMATION 其他信息

Type N/A if an item is not applicable.
请写N/A，如果这个问题不是适用于您。

Occupation (or prior occupation) 职业（或者前职业）*

Are you on any forms of disability? 您有工伤表格要填写吗？*

Do you have third party drug coverage? 您有第三方药物保险保费吗？*

Do you have dietary restrictions? 现在饮食有什么注意的吗？*

Previous Family Medical History 以前家族中是否有这些疾病？

Are you submitting this form for your 0-12 year old child? 您是否带您的0-12岁的孩子来看病？*

Yes 是No 否

What was your birth weight? 出生时候体重？

Any pediatrician you saw? 您之前看过儿科专家吗？

What was your birth length? 出生时候身长？

What was your birth head circumference? 出生脑围多少？

Was there any complications during the pregnancy or around the time of labor? 出生的时候是自然出生，剖腹产，出生有什么健康问题？

J-Von Medical Clinic Policy

I/WE have read, and agreed to the following:

ICBC and WCB cases need to be closed before the doctor can accept you as a new patient. This is to ensure continuity of your care.
Due to the high volume, our office encourages patients to discuss 1-2 medical issues per visit. If it is an emergency, the doctors with consider extra time discussing the issue. But if it is not an emergency, doctors will prioritize them in the allotted time and may ask you to schedule a follow-up visit to go through each issue thoroughly.
Once you are assigned to a family doctor, we will make every effort to book you an appointment with them. If your doctor is not available on the day you need to see a doctor, ie: emergency, we will book you with one of the other doctors that are on duty.
Please see your own family doctor for your care. You cannot switch your family doctor in this clinic
Please note we do not discuss lab reports or prescribe medication over the phone. Please book an appointment.
Please ensure your phone number has voice mail capability, if not please provide us with a secondary contact number and email address. We ask this so we can contact you with any information regarding your care and specialist offices or other medical facilities may contact patients directly. If you have changed your phone number or address please remember to update it with us.
No Show Charge is $60; please provide a minimum 24-hour notice. No show charge appointment needs to be paid prior to the next appointment.
In consideration of staff and other patients please supervise your children while in the waiting room and patients rooms. We are not responsible for their safety.
It is our best interest to keep our appointments on schedule, if we do run into delays, please kindly wait and do not push the front staff for timing. We understand your time is valuable.
Please do not use your cell phone in the reception area and room.
Please note that we do not prescribe narcotics or benzodiazepines
If you went to the hospital for an emergency, please tell the hospital the doctors’ name instead of the clinic’s name since our system will not recognize clinic names but doctor names so your files can be linked together.
When doctors leave our practice, you can follow the doctors to the new office.
I understand that some services are not covered by the provincial Medical Services Plan. Please ask staff and doctors for cost before you book the appointment. For example transfer to other clinics, sick notes, printing cost, forms, etc.
We have online booking. After you are a registered patient in our system we only accept online booking. We only help patients book online if patients are seniors, or having technical difficulties, or first-time patient.
Any rude or verbal languages or rude behavior(verbal abuse, violence, threats, harassment and damage property) are unaccepted by our clinic. You may be asked to leave!

Following is the Chinese Version of the clinic policy:

以下是诊所规定的中文版本:

J-Von 医疗中心诊所规定

我/我们已经读了条款，并同意遵守诊所条款：

因为家庭医生短缺，诊所每天会有很多病人希望就诊。请病人每次看诊尽量问1-2 个医疗问题. 如果您是遇到医疗紧急(emergency) 情况：医生会给您作详细的检查，会询问很多的问题不会当做单一问题处理。但是如果您不是性命攸关的紧急情况，医生会在规定的时间内优先考虑病情，并可能会要求您安排后续访问以彻底解决每个问题，请您跟前台再约一个时间。
ICBC，WCB 的案件需要结案之后，家庭医生才能接受您为新病人，因为初次见面医生不了解之前的ICBC WCB的情况。
诊所不会在电话里面讨论报告结果，如果您做了检查请记得回来诊所看报告。报告结果有问题的话, 需要复诊治疗。检验结果正常医生也要回来复诊，因为医生会考虑需不需要做其他的检查以确保病因。
很多病人的电话不开设留言，有时候专科医生会直接给病人打电话告诉预约时间，请您提供留言电话，或者更多电话给其他医疗机构方便联系您。邮箱请提供给我们诊所，我们需要随时联系你关于病情。
预约之后不通知取消预约，会有$60收费 . 麻烦您交齐之后才能下次预约。取消通知时间至少提前24小时。
小朋友不能在诊所里面跑来跑去，不能大声喊叫。请父母看好小朋友。小朋友和大人都不能用手碰触卷闸门，卷闸门我们已经用绳子捆好，如果小朋友还是自行打开一旦发生意外诊所不承担责任。家长请看好小孩子，诊室里面的器械也不可以用来玩耍。
医生看病的时间很难能够准确维持，所以难免需要您等待。请您耐心等待，只要您已经通报名字给给前台工作人。到时间前台工作人员一定会通知您进入房间就诊。请不要不断询问前台时间。
请您不要在前台和房间里面使用手机打电话。请您遵守诊所的秩序。
当您需要急诊的时候，提醒您跟医院的机构提供医生的名字而不是诊所的名字，因为您的报告回到诊所的时候，电脑系统只会识别医生名字。
如果您的家庭医生离开我们诊所，您可以继续跟随您的医生去新的诊所。
如果您转到别家诊所，我们这边会将材料整编发到新的诊所，我们会收取$50手续费用。每次在我们这边打印报告我们是收$1一张。如果是验血报告，您可以跟lab 设立在网上看报告，请咨询lab 这样就不必在诊所打印支付费用。其他有些表格政府需要医生帮忙填写，不包括在看诊里面，需要单独收费，请咨询前台和医生之后再约诊。
我们诊所提供网上预约，注册之后可以在网上直接预约。我们会帮忙这些病人：A没有电脑的长者，B或者出现网络问题故障，C新病人没有来过诊所的病人。正常的情况下病人请到网站上直接预约。预约步骤已经贴出在诊所前台和房间里面。
谁是您的家庭医生，请您约自己的家庭医生，因为这样他/她对您的情况了解，如果您的医生不在，您紧急生病了，我们可以帮您约其他座诊医生，但是我们这边没有换家庭医生的情况来注册时候你找哪位医生那位医生就是您的家庭医生。其他的情况都是walk in 病人。
我们诊所不接受任何不礼貌的言语和行为(包括语言暴力，责骂，骂人，恐吓，毁坏诊所物件)。请您尊重我们的医生和工作人员。性质恶劣者会被通知离开诊所!

Signature (after you read the policy) 签名（在您阅读规定之后）*

Date 日期*

Month-Date-Year 月-日-年

New Patient Registration Form & J-Von Medical Clinic Policy Agreement

J-Von 医疗中心诊所规定 & 新病人注册表格