Walk-in Clinic and Pharmacy
(204) 282-6699
(204) 943-5495
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(204) 282 - 6699
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Name
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Please Enter your legal First Name & Last Name
Date of Birth
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Please enter your Date of Birth
Day Time Phone Number
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Work Phone Number
Your Gender
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PHIN
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Your Personal Health ID Number
Address
Email
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Emergency Contact Name
In the case of Emergency, who should we contact?
Relationship
Emergency Phone Number
Do you have a Family Doctor
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If YES, what is your Family Doctor's Name?
Why are you wanting to switch doctors?
Past Medical History
Surgical History
Family Medical History
Allergies
List Any Medication You Are Currently Taking
Dosage Of Medication
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Are You On Any Narcotic/Controlled Medication Regularly?
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NO
If Yes, Which Medication
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Social Habits (Smoking/Alcohol Consumption/Use of Drugs)
Other Information
If you have any other information you think it will help your doctor to know, please, list it here.
Please Note:
This form is for information purpose only and not an agreement to becoming a new patient for a doctor. Any omission of information for falsifying information may lead to immediate rejections. You will be contacted by phone if accepted to schedule a first visit appointment.
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(204) 282 - 6699