Clinic: Patient Registration Form

Patient Registration & Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Gender

Address

Phone

Last Name

Date of Birth

Postal Code

Email Address

Health Card (with 2 letters)

Upload Health Card

Please answer to the best of your knowledge

Do you smoke?

Yes

If you answered yes to the question, please elaborate what kind, quantity per day, have you tried to quit and how long ago?

Do you drink alcoholic beverages?

Yes

If you answered yes to the question, please indicate how often (e.g. one glass a day, two bottles a week).

Have you used or do you use Cannabis?

Yes

If you answered yes to the question, how often & how much?

Other Drug Use?

Yes

If you answered yes, please indicate what kind and how often?

I declare that the info I’ve provided is accurate & complete

I acknowledge and understand the privacy policy and consent to the collection, use, and disclousre of my personal health information within Cadence Health Centre, laboratory, pharmacy, and to other healthcare providers, insurers, and where required by law for the purposes of providing or assisting in the provision of health care services to me.

TREATMENT OF PATIENTS RESIDING OUTSIDE OF CANADA (NON-OHIP PATIENTS) The patient agrees that the relationship between himself/herself, doctors and healthcare providers of Cadence Health Centre shall be governed by and construed in accordance with the laws acknowledges that the treatment/services was performed in the province of Ontario and the courts of the province of Ontario shall have jurisdiction to entertain any complaint, demand, claim or cause of action whether based on alleged breach of contract or alleged negligence arising out of the treament. The patient hereby agrees that he/she will commence any such legal proceedings in the province of Ontario and only in the province of Ontario and hereby submits to the jurisdiction of the courts of the province of Ontario.

Charges and penalty may apply for late cancellation and no show (Please see clinic fees)

By signing below, you consent/agree to the terms and conditions of this registration

Patient/ Legal Guardian Signature

Today's Date

Thanks for submitting!