Apply For Family doctor - Express Medical Care

Please complete this form to apply for a family doctor. If you would like to speak with us on the phone, do not hesitate to call us at 204‑306‑4259.

Patient Demographies

Name:

Date of Birth (MM/DD/YY):

Email address

PHIN#(9 digits):

MHC#(6 digits):

Gender

Any ALLERGIES, specify:

Address:

Preffered Phone Number?

Home:

Cell:

Can we leave messages on your preffered phone number? Yes, any messagesAppointment information onlyNo messages

How did you hear about us?

Preferred Pharmacy

Name:

Address:

Tel:

Fax:

Emergency Contact

Name:

Relationship to you:

Tel:

Social History

Country of Origin:

Language Spoken:

Occupation:

Marital Status:

Spouse/Partner's Name:

Medical History

Name of Previous Family Physician:

Clinic Name:

Clinic Location:

Do you smoke cigarettes? YesNo

If YES, how many do you smoke per day?

If No, did you ever previously smoke cigarettes? YesNo

When did you quit?

How many alcholic beverages, if any, do you drink per week?

Pertinent Medical History

Previous Hospitalization/Surgeries

Family History Of Medical Illness

Social History
Medications: All Prescribed Medications and Over the Counter (OTC) Medications