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: