Healing Hub Medical Centre

15229 Russel Avenue, White Rock, BC V4B 5C3
Tel: 778-537-2534 | Fax: 778-375-5410

New Patient Intake Form

Surname

First Name

Date of Birth

Personal Health Number (PHN)

Gender

Home Address

Phone (Cell)

Phone (Home)

Phone (Work)

Preferred Pharmacy

Emergency Contact (Name, Relationship, Phone)

Family Members at Clinic

Previous Family Physician

Current Medications

Allergies

Medical History (Check all that apply and specify year of onset)

Other Medical Conditions

Surgical History (Check all that apply and specify year)

Other Surgeries

Family History (Check all that apply)

Other Family History

Gynaecology/Obstetrics History (Females)

Last Menstrual Period (LMP)

Cycle Length

Total Pregnancies

Live Births

Abortions/Miscarriages

Contraception

Preventive Care Checklist (Check and specify last test date)

Pap Smear

Other (Disability, Insurance Company)

Please be aware that completing and submitting this patient intake form does not guarantee acceptance as a patient at this clinic. Due to limited availability, patients on the waitlist will be contacted to schedule an initial meet-and-greet with a family physician when spots are available. Kindly wait until you have been officially accepted before transferring any medical records.

Printed Name of Patient/Guardian

Signature

Date Signed