First Name *

Last Name *

Date of Birth *

Health Card # *

Phone *

Address: *

Email

List 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:

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