Patient Intake FormPlease fill out the form before your appointment. Name * First Name Last Name Date of Birth * MM DD YYYY Healthcard Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Medical History Do you suffer from Diabetes? * Yes No If yes, please specify Type 1 or Type 2: Do you suffer from any Chronic Illnesses? * Yes No If yes, please bring all medications or list of medications to the appointment. Do you have any allergy to any medication? * Yes No If yes, please specify: Have you conducted a medication review prior? * Yes No If yes, at which pharmacy or medical institution? Do you require screenings to be completed during this appointment? * Yes No Reason for visit? * Primary Care Provider Name * Phone * Country (###) ### #### Fax * Country (###) ### #### Thank you!