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

Doctor Requested

Referred by

Do You Currently Have A Doctor

NoYes

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