ACCEPTING NEW PATIENT

New Patient Registration Form

Please fill in the form below.

• Name *
  First

  Middle

  Last
• Age *
• Preferred Name or Nickname
• Patient's gender
  MaleFemale
• Next Kin
• Address
  Address Line 1 *

  Address Line 2

  City *

  State *

  Zip Code *

  Country *
• Health Card # *
• Patient Birth Date *
• Home Phone *
• Work Phone
• Cell Phone *
• Patient E-Mail *
• Your Pharmacy Name and Address
  Address Line 1 *

  City *

  State *

  Zip Code *
• Pharmacy Fax # *
• Pharmacy Phone # *
• Work Status
  Employed Unemployed Retired Disabled fom work
• Marital Status
  Single Married Widowed Divorced Separated Domestic Partner
• Do you use tobacco in any form?
  Yes No
• If yes, please list type , amount and frequency of use
• Do you use Alcohol in any form?
  Yes No
• Do you use Alcohol in any form?
• Are you taking any medication? If yes, please list medication and doage per day
• Abnormal Bleeding
  Yes No
• Alcohol Abuse
  Yes No
• Allergies
  Yes No
• Anemia
  Yes No
• Angina Pectoris
  Yes No
• Arthritis
  Yes No
• Artificial Heart Valve
  Yes No
• Asthma
  Yes No
• Blood Transfusion
  Yes No
• Cancer
  Yes No
• Chemotherapy
  Yes No
• Congenital Heart Defect
  Yes No
• Diabetes
  Yes No
• Difficulty Breathing
  Yes No
• Drug Abuse
  Yes No
• Emphysema
  Yes No
• Epilepsy
  Yes No
• Facial Surgery
  Yes No
• Fainting Spells
  Yes No
• Fever Blisters
  Yes No
• Frequent Headaches
  Yes No
• Glaucoma
  Yes No
• HIV + AIDS
  Yes No
• Heart Attack
  Yes No
• Heart Murmur
  Yes No
• Heart Surgery
  Yes No
• Hemophilia
  Yes No
• Hepatitis A
  Yes No
• Hepatitis B
  Yes No
• Hepatitis C
  Yes No
• High Blood Pressure
  Yes No
• Joint Replacement
  Yes No
• Kidney Problems
  Yes No
• Liver Disease
  Yes No
• Low Blood Pressure
  Yes No
• Mitral Valve Prolaps
  Yes No
• Pace Maker
  Yes No
• Psychiatric Care
  Yes No
• Radiation Therapy
  Yes No
• Rheumatic Fever
  Yes No
• Seizures
  Yes No
• Sexually Transmitted Disease
  Yes No
• Shingles
  Yes No
• Sickle Cell Disease
  Yes No
• Sinus Problems
  Yes No
• Stroke
  Yes No
• Thyroid Problems
  Yes No
• Tuberculosis
  Yes No
• Ulcers
  Yes No
• Are you currently in pain?
  Yes No
• Additional Comment
•  

PLEASE NOTE ONLINE APPOINTMENT IS ONLY AVAILABLE FOR PSYCHOTHERAPY AND COUNSELING FOR NOW
CLICK the button TO BOOK APPOINTMENT ONLINE

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Opening Hours:

OUR SERVICES

• 
  Family Physician
  
• 
  Psychological Services: Clinical Counseling and Psychological Testing
  
• 
  Pediatrician (Referral Only)
  
• 
  Psychiatrist (Referral Only)
  
• 
  International Medical Consult
  
• 
  Weight Management/Wellness
  
• 
  Work/School/Travel
  
• 
  Walk in clinic
  
• 
  Travel clinic
  
• 
  Medical Esthetics
  
• 
  Immunizations
  
• 
  Skin Procedure/Cosmetic Surgery