NEW PATIENT INTAKE FORM

Name *

First Name

Surname *

Last Name

Date of Birth *

Gender *

OHIP Health Card Number & Version Code *

please ensure you type the 10 digits & TWO letters on the health card

Email

Home Phone

Cell Phone *

Address *

Address

City

Province

Postal

Pre-existing medical conditions *

Please be advised that this list is just to help the doctor understand your needs in preparation for your first appointment. NO patient will be turned down based on their pre-existing health conditions.

Additional medical notes

Please list medical problems with the year of diagnosis.

Any previous surgery?

Please list any previous surgery with date

Up to date with mammograms? ( Breast Cancer screening) * Up to date with mammograms? ( Breast Cancer screening)

If you are age 50 to 74, the Ontario Breast Screening Program recommends that most women in your age group get screened with mammography every 2 years. If you are 30-69 and you are at high risk of breast cancer please discuss this with your doctor.

Up to date with PAP smear? * Up to date with PAP smear?

Women should begin screening for cervical cancer at age 21 if they are or have ever been sexually active. Women who are not sexually active by age 21 should delay cervical cancer screening until they are sexually active. Sexual activity includes intercourse, as well as digital or oral sexual activity involving the genital area with a partner of either sex. Screening is every 3 years until age 70 unless there is history of abnormal results.

Significant Family History

Current medications & dosage *

Allergies

Immunizations

Type immunization along with the date if known

Social background

Please write the name of the family doctor you would like to register on the waitlist for ( current waitlist times 6-12 months)

Emergency contact or next of kin name *

Emergency Contact Phone *

Relationship

How did you hear about us? * How did you hear about us?

Checkboxes

Option 1

Option 2

Contact Us

Working Hours

Pages

Health News