Patient Intake Form

Visit History Have you been treated at this hospital before? Yes Not sure No / First visit

Healthcard Information Do you have a Canadian health card? Yes No

Province

You can scan your health card to automatically populate your details, or manually enter them below.

Scan Health Card

Preview

Health Card Number Expiry Date (Optional)

Patient Information Full Name Date of Birth

Patient Information Full Name Date of Birth Sex (Optional) Phone Number

+1

Email Address (Optional)

Parent / Guardian (If applicable) Is a parent / guardian applicable for this patient? Yes No

Name Relationship Phone Number

+1

Emergency Contact Has your emergency contact changed since your last visit? Yes No

You can update your emergency contact information below, or leave it blank and a nurse will help you update it later.

Name (Optional) Phone Number (Optional)

+1

Relation to the patient (Optional)

Emergency Contact Information

You can add an emergency contact below, or leave it blank and a nurse will help you add one later.

Name (Optional) Phone Number (Optional)

+1

Relation to the person (Optional)