New Patient Application

REGISTRY INFORMATION

First Name*

Last Name*

Date Of Birth*

Gender* MaleFemale

Manitoba Health Card Number* HOW TO FIND

Personal Health Identification Number* HOW TO FIND

CONTACT INFORMATION

Day Phone*

Evening Phone*

Email*

Street Number & Address*

City*

Province* ManitobaAlbertaBritish ColumbiaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Postal Code*

EMERGENCY CONTACT

First Name*

Phone*

Relationship* —Please choose an option—ParentalSiblingChildGrandparentFamily OtherGuardianFriendCoworkerEmployerLegal

DOCTOR INFORMATION

Do You Currently Have A Doctor?*—Please choose an option—NOYES

Were You Referred By Another Doctor?*—Please choose an option—NOYES

Which Doctor Are You Requesting?*NO PREFERENCEDr. Sajjad Hashmi, FAMILY PHYSICIANDr. Davinder Khangura, FAMILY PHYSICIANDr. Mohammad Moghareh, FAMILY PHYSICIANDr. Robert Obara, FAMILY PHYSICIANDr. Silvia Vignudo, FAMILY PHYSICIANDr. Tavis Bodnarchuk, PEDIATRICIANDr. Stacey Bynkoski, PEDIATRICIANDr. Jonathan Gabor, CARDIOVASCULAR & CARDIOMETABOLIC DISEASEDr. Alan Guktin, PSYCHOLOGISTDr. Taghreed Hassan, PSYCHIATRISTDr. Sherief EL-Gally, PSYCHIATRIST

MEDICATION & NARCOTIC HISTORY

Do You Have Any Allergies To Medications? —Please choose an option—NONEYES

Do You Use Narcotics Regularly? EXAMPLES —Please choose an option—NONEYES

Smoking History —Please choose an option—Non-SmokerSmokerEx-Smoker

MEDICAL HISTORY

Family History* Not ApplicableCancerHeart DiseaseUnknown

Your Brief Medical History

Alzheimer's DiseaseAnxietyArthritisAsthmaCancerChronic Fatigue SyndromeDepressionDiabetesFibromyalgiaHeart DiseaseHepatitisHigh Blood PressureHigh CholesterolLong Term Back PainLong Term PainMyocarditisParkinson's DiseasePericarditisPsychiatric HistoryNot Listed

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.

PLEASE NOTE* You must present your MANITOBA HEALTH CARD and VALID IDENTIFICATION in person upon visit.

I have supplied the above information to the best of my knowledge. I have read the terms and accept these as outlined above.

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