SECURE PATIENT ACCESS

New Patient Intake Form

Use Next and Back to complete all required sections. Your information is not submitted until the final step.

Step 1 of 11

1. Patient Information

First Name *As it appears on the health card

Last Name *As it appears on the health card

Date of Birth *

Gender *

MaleFemaleGender X

Occupation *

Marital Status *

OHIP Health Card Number & Version Code *

Private Drug Plan

2. Contact & Emergency Contact

Street Address *

Address Line 2

City *

Postal Code *

Province *

Email *

Cell Phone *

Home Phone

Children (if applicable) Name & Age

Emergency Contact Name *

Contact Number *

Emergency Contact Relationship *

3. Preferred Pharmacy

Select a pharmacy already maintained by the clinic, or choose Other / Pharmacy Not Listed and enter all contact details. Fax may be entered as Not Applicable.

Preferred Pharmacy

Pharmacy Name

Phone

Fax

Address 1

Address 2

City

Province

Postal Code

Pharmacist Name

8. Lifestyle

Tobacco Use *

Quit Date

How much? *

How long? *

Alcohol use? *

Other drugs used? (Current or in the past) *

Exercise *

Dietary Restrictions *

9. Vaccination & Other Medical History

List the most recent year and location where applicable.

Tetanus Vaccine *

Flu Vaccine *

Current Medications (including OTC medications and vitamins) *

Allergies & Reaction *

10. Financial & Current Concerns

Any trouble making ends meet at the end of the month? *

Date of Application *

Please list any active medical concerns you wish to discuss *

11. Patient Acknowledgement & Review

Blue-Vertigo Medical Clinic may contact you by email or phone regarding appointment scheduling, referral bookings, general clinic information and test results.

Privacy and use of Internet & Email: Internet communication is not 100% secure. The clinic uses privacy-conscious systems, but cannot guarantee absolute confidentiality once a message travels across the Internet. Avoid using a work email if your employer may archive or inspect messages. Email must never be used for an emergency; in an emergency call 9-1-1 or attend the nearest emergency department.

I acknowledge and accept the risks associated with using email with Blue-Vertigo Medical Clinic. * I affirm that all information and answers are complete, true and correct to the best of my knowledge and belief. *

Typed Patient / Representative Signature *

← Back

New Patient Intake Form

1. Patient Information

2. Contact & Emergency Contact

3. Preferred Pharmacy

4. Personal Medical History

5. Personal Medical History — Continued

6. Family Medical History

7. Family Medical History — Continued

8. Lifestyle

9. Vaccination & Other Medical History

10. Financial & Current Concerns

11. Patient Acknowledgement & Review