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info@unitymedicalcentre.ca
2579 King St E, Hamilton
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New Patient Intake Form
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Intakes & Resources
New Patient Intake Form
Resources
Our Story
Our Services
Blog
Contact Us
Book Appointment
New Patient Intake Form
Patient Name
(Required)
First
Date Of Birth
DD slash MM slash YYYY
Health Card
(Required)
What's Your Gender?
(Required)
Male
Female
Other
Patient Address
(Required)
Telephone (Cell)
(Required)
Telephone (Home)
Email
(Required)
Do You Have A Family Doctor?
Yes
No
Who Is Your Current Family Doctor
(Required)
Medical History (please check all that is relevant)
Heart Disease
Stroke
High Blood Pressure
Blood Clot
Cancer
Diabetes
Currently pregnant
Currently breast feeding
Surgeries/procedures
Mental health
Other
Surgeries/procedures, please specify:
Mental health, please specify:
Other, please specify:
Please indicate any allergies to medications and your reaction:
Please list all medications and supplements that you take on a regular basis:
Preferred pharmacy (name and location):
Social history
Occupation:
Marital Status:
Diet, please specify if you follow a specific diet
Please check all that applies:
Smoking (tobacco)
Alcohol
Marijuana/cannabis
Other substances
Preventative Care, please check if completed and indicate the most recent test/vaccine:
PAP
Tdap/Adacel
FIT/FOBT/stool test
Colonoscopy
Flu vaccine
Mammogram
Bone mineral density
COVID vaccine
Is You Have Received Any Vaccinations Above Write Out The Time Below
Consent for communication I give permission for the office staff to leave messages regarding upcoming appointments, or to leave messages to phone back the office for test results or other communications
(Required)
Yes
No
In case of emergency, please contact:
Name
First
Relationship
Phone
I give permission to leave messages containing medical information and instructions to the following people (include translators if needed)
Name
First
Relationship
Phone
Name
First
Relationship
Phone
Patient Name:
Date:
Signature
