Patient Intake Form

Register as a New Patient

Complete the form below to help our care team understand your health needs before your visit. All information is kept strictly confidential.

Patient Intake Form

Please fill out the following form to help us understand your physical condition.

All information you provide is kept confidential and used solely to support your care.

Patient Information

First Name

Last Name

Email Address

Phone

Health Card #

Health Card Version Code

Date of Birth * required

Gender/Sex

Address

City

Province

Postal Code

Emergency Contact

Contact 1

Name

Relationship

Phone

Contact 2

Name

Relationship

Phone

Health History & Concern

(symptoms, diagnosis, duration, onset)

Health Concern

When Did It Start?

Allergies

Medications

Are you currently suffering from a medical condition, illness, or injury? * required

No Yes

Have you been hospitalized in the last 12 months? * required

No Yes

If you answered yes to any question, please elaborate

Declaration

I declare that the information I've provided is accurate and complete to the best of my knowledge.

Initials

Today's Date

What Happens Next

We'll Review Your Information Before Your Visit

Once submitted, our care team will review the information you've provided to prepare for your visit. Your details are handled with full confidentiality.

Your Privacy is Protected

Your information is kept strictly confidential and shared only with your care team.

Prepared Before You Arrive

Our team reviews your intake form before your appointment so your visit runs smoothly.

Have questions? Contact Us