New Patient Intake Form

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New Patient Intake Form

Please fill out and print clearly.

Email *

Record my email address with my response

Last Name *

*First Name:

*Home Address:

Home Phone:

*Cell Phone:

City:

Postal Code:

Work Phone:

Email *

Date of Birth: *

YYYY

Sex: *

Non-binary

Required

Personal Health Number: *

Emergency Contact Name, Relation & Phone: *

Previous Family Doctor: *

Reason For Visit: *

Past Medical History: *

Past Surgical History: *

List of Current Medications: *

Allergies: *

Names of specialists involved: *

Do you smoke? Yes/No - If YES how long:

Do you drink alcohol: Yes/No - if YES, How often?

Occupation:

Do you have extended benefits? Yes/No

Family History of any cancers or heart disease (<65 years of age)?

Preferred Pharmacy (Name & Location):

Last Mammogram & Results:

Last Pap Smear & Results:

Last FIT Test & Results:

Last Bone Scan (DEXA) & Results:

Last Abdominal Ultrasound & Results:

Patient consents to Pharmanet/Careconnect (Medication and medical history access):

Yes

Clear selection

Patient consents to Email and Electronic Communication: *

Yes

Signature:

A copy of your responses will be emailed to .

Submit

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