test-page – Health Hub Medical

Name *

Please Enter your legal First Name & Last Name

Date of Birth *

Please enter your Date of Birth

Day Time Phone Number *

Work Phone Number

Your Gender

PHIN *

Your Personal Health ID Number

Address

Please enter your email, this could be used to contact you and following with you

Emergency Contact Name

In the case of Emergency, who should we contact?

Relationship

Emergency Phone Number

Do you have a Family Doctor

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?

If Yes, Which Medication

Dosage Of 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.

Name