Patient Intake Form

Your privacy is very important to us. Any information you enter here is protected by law. This form is transmitted via an encrypted, secure connection and cannot be viewed by third parties. If you are using a public computer, be sure to clear your history and sign out before leaving.

This form is intended to be used in a desktop or tablet browser. It may not display correctly on some cell phones.

Click here to download and print the Patient Intake Form as a PDF.

General Information

First name (required)

Middle name

Last name (required)

Your age

Date of birth:

Marital status:

Gender:

Biological sex: malefemale

Your contact information:

Address Line 1:

Address Line 2:

City:

Province:

Postal Code:

Can messages be left confidentially? YesNo

Home phone:

Cell:

Business:

Your email

About you:

Your occupation:

Medical doctor:

Date of last physical exam:

Were blood tests done? YesNo

How did you find out about the clinic?

Emergency Contact(s):

Name:

Relation:

Phone:

Name:

Relation:

Phone:

Name:

Relation:

Phone:

If you would like to share any additional introductory information with the doctor, you may do so here. Your doctor will take a detailed history from you during your initial consultation.