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** —Please choose an option—MaleFemale Contact Information Day Phone** Evening Phone** Email Address** Street Address** City** Unit/Suite Province** AB - AlbertaBC - British ColumbiaMB - ManitobaNB - New BrunswickNL - NewfoundlandNT - Northwest TerritoriesNS - Nova ScotiaNU - NunavutON - OntarioPE - Prince Edward IslandQC - QuebecSK - SaskatchewanYT - Yukon 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
