Please enable JavaScript in your browser to complete this form.First Name *Last Name *Date of Birth *Health Card # *Phone *Address: *EmailList all medications including over the counter medicines and herbal or other medicines:List of medical conditions you have (knowing these conditions is important for your treatment plan including medications):List any known allergies or sensitivities:Specialists: Are you or have you been under the care of a Specialist please provide name(s) and reason:The reason for your visit. Is is helpful to know the general reason for your visit:Name of previous family doctor or nurse practitioner if any and location:Name of preferred pharmacy (we will fax prescriptions directly to your pharmacy):If you want to add any information, please do so here:Agree to be contacted *YesNoWebsiteSubmit