REGISTRY INFORMATION

    CONTACT INFORMATION


    EMERGENCY CONTACT

    DOCTOR INFORMATION

    MEDICATION & NARCOTIC HISTORY

    MEDICAL HISTORY

    Family History*

    ACKNOWLEDGMENTS

    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.
    You will be charged for any missed appointments without 24 hours notice, and any phone or fax prescription renewals.
    PLEASE NOTE* You must present your MANITOBA HEALTH CARD and VALID IDENTIFICATION in person upon visit.