New Patient Application
Genetica Medical & Wellness Centre
Preferred Provider Request
*
Please Select
First Available
NP Rebecca Countess
NP Natalia Elmajian
NP Taran Gill
NP Shane Inocencio
Dr. Kate Wang (not accepting)
First & Last Name (as it appears on your care card)
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First Name
Last Name
Preferred Name
Assigned Sex at Birth
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Please Select
Male
Female
Prefer not to answer
Current Gender Identity
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Preferred Pronouns
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E.g. She/Her, He/him, They/Them, Zi/Zir
Date of Birth
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-
Month
-
Day
Year
Date
Care Card Number
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Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you referred by the Health Connect Registry?
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Please Select
Yes
No
Name of current or previous Medical Doctor/Nurse Practitioner
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Rationale for leaving current medical provider?
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Height
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E.g. 5ft 7 inch
Weight
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E.g. 145 lbs
Please list your diagnosed medical and mental health conditions
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Please list previous surgeries and their dates completed
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Do you have any specialists currently involved in your care?
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E.g. Cardiologist, Gastroenterologist, ENT
Please list your current medications with doses and frequencies
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Please list your current vitamins or supplements
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Do you have any medication, food, or environmental allergies? If yes, please state which ones and your allergic reactions
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Are your immunizations up to date?
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Yes
No
Unknown
Biological father age and medical history
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E.g. Age 75, Hypertension, Type 2 Diabetes
Biological mother age and medical history
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E.g. Age 64, Hypothyroidism, Chronic Kidney disease
Sibling age and medical history
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Occupation
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E.g. Accountant, Lawyer, Student, Unemployed etc
Are you on disability?
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Please Select
Yes
No
Describe your family life (who lives in your home, relationship status, children)
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Do you exercise? If yes, how many times per week?
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Special dietary restrictions?
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E.g. Vegetarian, Gluten free, Vegan
Do you smoke cigarettes? If yes, how many per day?
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Do you vape? If yes, how much per day?
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Do you drink alcohol? If yes, how many drinks per week?
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Do you use recreational drugs? If yes, what type and how much per day?
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Please list your current medical concerns or goals
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Your preferred pharmacy
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How did you hear about us?
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By signing below, I acknowledge that I have read, understood, and agree to comply with the clinic's Late Arrival and No-Show Policy. I understand that if I arrive more than 5 minutes late for my appointment, it may be rescheduled, and a late/no-show fee of $50 will be applied to my account. I also understand that this fee must be paid before I can reschedule the appointment. Furthermore, I understand that I should notify the clinic at least 24 hours in advance if I need to cancel or reschedule to avoid any charges.
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