NEW Patient Intake form for Family Doctor

NEW Patient Intake form for Family Doctor - Eglinton Ave W, Unit 46, Mississauga

Med Square Medical Centre

Located at 4188 Living Arts Drive, Unit 5 , Mississauga

Do you have a family doctor ?

Gender

Marital Status

Name as Appear of HEALTH CARD or ID

Brithday

Do you have Children?

Name as Appear of HEALTH CARD or ID

Occupation (Job)

Do you have the Ontario Health Card or IFHP Coverage (BlueCross)?

Address*

Street Address

Street Address Line 2

City

State

Zip Code

Country

Home Phone Number

Children (if applicable) Name & Age

Emergency Contact Relationship

How Did You Hear About Us?

Phone/Mobile

Work Phone Number

Emergency Contact Name

Phone

Personal Medical History

Personal Medical History (Check any illness/conditions YOU have had)

illness/conditions

High blood pressure

High cholesterol

Kidney disease (specify)

Thyroid problems
(specify)

Lung disease (specify)

Blood cot (specify)

Tuberculosis

Blood disorder (specify)

Skin condition
(specify)

Asthma

Heart condition (specify)

Arthritis

Gastrointestinal issues (specify)

Stroke

Diabetes

Hepatitis A/B/C
(specify)

Osteoporosis

Cancer (specify)

Anxiety/Depression

Others (specify)

Non

Select Yes

Yes

Specify

High cholesterol

Kidney disease (specify)

Thyroid problems (specify)

Lung disease (specify)

Blood cot (specify)

Tuberculosis

Blood disorder (specify)

Skin condition (specify)

Asthma

Heart condition (specify)

Arthritis

Gastrointestinal issues (specify)

Stroke

Diabetes

Hepatitis A/B/C (specify)

Osteoporosis

Cancer (specify)

Anxiety/Depression

Others (specify)

Family Medical History

Family Medical History (Check any illness/conditions your immediate FAMILY has had)*

illness/conditions

High blood pressure

High cholesterol

Kidney disease

(specify)

Thyroid problems (specify)

Lung disease (specify)

Blood cot

(specify)

Tuberculosis

Blood disorder

(specify)

Skin condition

(specify)

Asthma

Heart condition (specify)

Arthritis

Gastrointestinal issues

(specify)

Stroke

Diabetes

Hepatitis A/B/C

(specify)

Osteoporosis

Cancer (specify)

Others

(specify)

Non

Others (specify)

Lifestyle

Tobacco Use

In the Past - Quit Date

Alcohol Use

Other Drug Use (Current or Past)

IV Drug ( please type name and what is used for)

Exercise

Dietary Restrictions

Private Drug Plan

Preventative Health (list the most recent year and location of each as applicable)

Tetanus Vaccine

Gender

Flu Vaccine

Additional VACCINATIONS (e.g. HEPATITIS A, typhoid, etc.)

CURRENT MEDICATIONS (including over-the-counter medications and vitamins. *attach a separate list if needed. Please write (NON) if you are not taking any medications. If you are adding medications, Please mention Name & Dose

Attach your list of medication if needed below: Image or PDF

Choose File

ALLERGIES & REACTION

FINANCIAL (Any Trouble Making Ends Meet at the End of the Month?)

Please List Any Active Medical Concerns You Wish to Discuss

Patient acknowledgement

WESN Health Clinic Will Contact You By Email or Phone to Inform You about

Appointment bookings and reminders

Referral bookings

General information about our office and clinics

Test results

If you intend to receive our emails, please remember to update your address book with our email, contact@wesnhealth.com, and check your Junk/Spam folder.

Privacy ,Using Internet & Email and consents:

Internet communication is not 100% secure. While we try to protect our patient by using advance-way of patient messaging systems approved by Ministry of Health and complaint with PIPDA for patient privacy protection, we cannot guarantee the security and confidentiality of any email or messages you receive from us. As the message leaves WESN Health Clinic, it is sent across the internet and it could be intercepted and read.

If you use a work email, your employer may have a right to archive and inspect emails sent from their systems. We recommend you avoid using a work email address.

WESN Health Clinic is not responsible for information loss due to technical failures.

Email should never be used in an emergency. If you have an emergency, you should call 9-1-1 or go to your nearest hospital emergency room or health care provider immediately.

I understand the risks associated with using email with WESN Health Clinic and I accept those risks.

RELEASE OF LIABILITY: I agree that WESN Health Clinic (and their physicians, staff, agents and officers) shall not be responsible for any personal injury including death, and/or privacy breach (outside the control of WESN Health Clinic) or other damages as a result of my choice to receive emails from the WESN Health Clinic and I release the WESN Health Clinic (and their physicians, staff, agents and officers) from any liability relating to communicating with me by email.

I understand if I no longer wish to receive WESN Health Clinic emails, I will write to Contact@wesnhealth.com

I understand I have the right to have legal advice about signing this form and what it means to me and I have either sought that advice or chosen not to seek such advice.

I have read and fully understand this consent and release form.

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief.

I acknowledge the existence of a waiting list and understand that submitting this request for family practice intake does not ensure immediate acceptance. Physicians accepting new patients will review applications in the order they were received. I will be contacted once I have been accepted, though the exact timing remains uncertain as availability depends on when spots open up.

Date

By clicking the submit button, I agree to terms & conditions

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