Patient Intake Form Template – Canada

The Patient Intake Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These versions are fully editable and printable, tailored to fit your requirements seamlessly.

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Sample

Patient Intake Form Template – Canada

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1. Patient Information




2. Emergency Contact


3. Health History

4. Current Medications

5. Allergies

6. Primary Care Physician


7. Reason for Visit

8. Additional Comments or Concerns

9. Patient Declaration


PDF

WORD

Examples

Patient Intake Form Template – Canada (1)
Patient Information:
[First Name]
[Last Name]
[Date of Birth]
[Gender]
[Contact Number]
[Email Address]
Address:
[Street Address]
[City]
[Province]
[Postal Code]
Emergency Contact:
[Emergency Contact Name]
[Relationship]
[Emergency Contact Number]
Medical History:
Please list any previous medical conditions, surgeries, or ongoing treatments: [Medical History Details]
Allergies:
Do you have any allergies? If yes, please specify: [Allergies Details]
Current Medications:
Please list all current medications including dosages: [Current Medications]
Reason for Visit:
Please describe briefly the reason for your visit: [Reason for Visit]
Insurance Information:
Insurance Provider: [Insurance Provider]
Policy Number: [Policy Number]
Patient Consent:
I consent to the collection and use of my personal health information for the purposes of my care and treatment.
Signature: _______________________
Date: [Date]
Patient Intake Form Template – Canada (2)
Patient Information:
[First Name]
[Last Name]
[Date of Birth]
[Gender]
[Contact Number]
[Email Address]
Address:
[Street Address]
[City]
[Province]
[Postal Code]
Referral Source:
How did you hear about us? [Referral Source]
Health Goals:
Please indicate your health goals or concerns: [Health Goals]
Family Medical History:
Please provide relevant family medical history: [Family Medical History]
Previous Treatments:
Have you had any previous treatments? If yes, please provide details: [Previous Treatments]
Consent for Treatment:
I authorize the medical staff to perform necessary examinations and treatments as clinically indicated.
Signature: _______________________
Date: [Date]

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Patient Intake Form Template - Canada