NEW PATIENT FORM

FOR FASTER RESPONSE, ALL SECTIONS MUST BE COMPLETED IN FULL.
ANY MISSING INFORMATION MAY RESULT IN NOT HAVING AN APPOINTMENT.
PLEASE NOTE THAT SOME DOCTORS’ PRACTICES MAY BE FULL FOR SOME CONDITIONS – WE WILL NOTIFY YOU.
IF THE FORM SUBMISSION IS NOT SUCCESSFUL, PLEASE RE-SUBMIT.

    Date* (DD/MM/YYYY)

    Name*

    Date of Birth* (DD/MM/YYYY)

    Gender* (Male/Female)

    Address Line 1*

    Address Line 2

    City*

    Postal Code*

    Home Phone*

    Cell Phone*

    PHIN# (9 digits) *

    MH# (6 digits)*

    Do you currently have a Family Doctor?YesNo

    If yes, Who is your Family Doctor

    Reason for switching

    Are you on any Narcotics or controlled medication regularly?YesNo

    Please give a brief medical history

    Please check ALL THAT APPLY:

    Alzheimer’s Disease YesNo

    Depression YesNo

    Long term back pain YesNo

    Anxiety YesNo

    Diabetes YesNo

    Long term pain YesNo

    Cancer YesNo

    Fibromyalgia YesNo

    Parkinson’s Disease YesNo

    AsthmaYesNo

    Heart Disease YesNo

    Psychiatric history YesNo

    Hepatitis YesNo

    High Cholesterol YesNo

    Chronic fatigue syndrome YesNo

    High blood pressure YesNo

    Arthritis YesNo

    Please include any other conditions if not listed here:

    Kindly provide your full List of Current medications: