PLEASE COMPLETE THIS FORM ONLY IF YOU WOULD LIKE TO BE ON OUR WAIT LIST

 

    Personal Information

    First Name**

    Manitoba Health Card Number**

    (6 Digits)

    Date Of Birth**

    Last Name**

    Personal Health Identification Number**

    (9 Digits)

    Gender**

    Contact Information

    Day Phone**

    Evening Phone**

    Email Address**

    Street Address**

    City**

    Unit/Suite

    Province**

    Postal Code**

    Emergency Contact

    First Name**

    Phone**

    Doctor Information

    Do You Currently Have A Doctor

    NoYes

    Referred by

    If Yes, Who Is Your Family Doctor


    Medical History

    Do You Have Any Allergies To Medications?

    If So, Please List

    Do You Use Narcotics Regularly?

    (Example: Morphine, Percocet, T3)
    NoYes

    Please List All Current Medications

    Smoking History

    Non-SmokerSmokerEx-Smoker

    Family History

    Not ApplicableCancerHeart Disease

    Brief Medical History

    (check all that apply)

    Alzheimer's Disease
    Anxiety
    Arthritis
    Asthma
    Cancer
    Chronic Fatigue Syndrome
    Depression
    Diabetes
    Fibromyalgia

    Heart Disease
    Hepatitis
    High Blood Pressure
    High Cholesterol
    Long Term Back Pain
    Long Term Pain
    Parkinson's Disease
    Psychiatric History

    Online Signature

    This form is for information purposes only and not an agreement to becoming a new patient for a doctor. You will be advised by telephone if accepted to schedule a meet and greet appointment. A meet and greet appointment is for information gathering ONLY. If you have medical concerns please make another appointment.

    By acknowledging, you are also Subscribing to be put on our notification list for important Public Service Announcements (P.S.A's) or Health Related issues as it pertains to the Winnipeg and/or Windsor Park Area. You may Unsubscribe at any time.

    Please note, you will be charged for any missed appointments without 24 hours notice, and any phone or fax prescription renewals.

    I have supplied the above information to the best of my knowledge. I have read the terms and accept these as outlined above.
    PLEASE NOTE* You must present your MANITOBA HEALTH CARD and VALID IDENTIFICATION in person upon visit