Patient Forms

Patient Forms2019-03-18T11:34:47+00:00

Patient Registration Form

Before coming in feel free to download the patient registration form OR fill out the form below.

Personal Information
Salutation
First Name*
Last Name*
Initials
Gender
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Address Information
Address*
City*
Province*
Postal Code*
Contact Information
Residential Phone*
Cell Phone*
Work Phone
Email
Preffered Method of Contact
Emergency Contact Name*
Emergency Contact Phone*
Insurance Carrier
Primary Insurance
Name of Insured
Date
Date Format: MM slash DD slash YYYY
Employer
Insurance Provider
Group Policy #
Division
ID / Certificate #
SIN #
Secondary Insurance
Name of Insured*
Date
Date Format: MM slash DD slash YYYY
Employer*
Insurance Provider*
Group Policy #*
Division
ID / Certificate #
SIN #
Medical History
Are you presently under the care of a Physician?
- Yes
- No
Have you been hospitalized in the past 2 years?
Are you taking any drugs or medications? Click the + button to add a new medication.
Have you ever had any allergies to any medication?
- Yes
- No
Which Medications?
Have you ever been warned against using any medication?
- Yes
- No
Which Medications?
Do you suffer from any non-drug related allergies?
- Yes
- No
List any non-drug related allergies
Are you allergic to latex?
- Yes
- No
Do you bruise easily or have prolonged bleeding?
- Yes
- No
Do you smoke?
- Yes
- No
How many per day?
Have you ever had chest pains?
- Yes