Apply for Family Doctor

First Name

Last Name

Email

Phone

Date of Birth

Gender Select * Male Female Other Perfer not to Answer

PHIN#(9 digits)

MHC#(6 digits)

Any ALLERGIES, specify:

Your Address

Preferred Pharmacy:

Name of Your Pharmacy

Pharmacy Phone

Pharmacy Fax

Pharmacy Address

Emergency Contact:

Name of Your Emergency Contact

Relationship to You

Phone Number

Social History:

Country of Origin Select * Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe

Occupation

Marital Status Select * Single Married Divorced Widowed Separated

Partner/spouse’s Name

Medical History:

Name of Previous Family Physician

Clinic Name

Clinic Location

Clinic’s Phone

• Yes
• No

How many per day?

• Yes
• No

How many per week?

Please mention your Previous Hospitalization/Surgeries

Please mention your Family History Of Medical Illness

Please mention your Medications: All Prescribed Medications and Over the Counter (OTC) Medications

How did you know about us? Select * Social Media Newspaper Google Search Referrals from a Doctor Word of Mouth Posters Outdoor Ads Radio

Your Message