New Patient Form

Full name *

City of Residence *

Date of Birth / Age *

Email *

Email

Confirm Email

Phone Number *

Alternative Phone Number *

Do you currently have a family doctor? *

Yes
No

If yes what is the name of the doctor?

What is the reason to switch doctors?

If you are applying as a family, please fill out their information in the following box (separated by comma)

Do you currently take Any narcotics? (i/e controlled substances: Morphine, Hydromorphone, Tramadol, etc) *

Yes
No

Do you currently take Any Recreational drugs? *

Yes
No

Do you have or ever had an ICBC claim(s)?

Do you have or ever had an WBC claim(s)?

Please be advised that we are unable to accept new patients who are actively looking to obtain medical leave from work or schools. *

I (We) agree
I (We) disagree

CONSENT TO PHYISCIANS FOR ACCESS TO YOUR MEDICAL INFORMATION : Physicians often need to review medical information of patients on different platforms e.g. Pharmanet and Care Connects for providing the best practice. Please indicate your choice from the drop box: *

I (We) agree
I (We) disagree

I hereby certify that the information provided here is accurate and true. I also declare that I understand the content of this form. *

yes

Today's Date *

Your Name *

Email