Patient Intake Form PATIENT INFORMATIONFirst Name*Middle NameLast Name*Gender*FemaleMaleGender NeutralDate of Birth* Date Format: YYYY slash MM slash DD Age*Phone Number*(you can be reached)Health Number*Health Number Version*One / Two Right Side LettersFamily Physician*AddressStreet Address*Address Line 2City*Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Main Reason for Visit*How did you hear about Clinic 360/Who referred you?Other friends or family members seen here?Email Address Please give us your email address, if we may communicate with you via email for future appointments?TREATMENTS OF INTERESTTreatments of Interest: Weight Loss Liposuction Eyelid Surgery Abdominoplasty (Tummy Tuck) Botox Juvederm / Restylane Facial Rejuvenation Breast Enhancement By Selecting any of these treatment, we will include you in our email list for the latest updates at Clinic 360Other Treatments of InterestHEALTH INFORMATIONDo you have any of these conditions? Heart Problems Diabetes Hepatitis / Jaundice Asthma Other Health ConditionsDo you smoke?*NoYesDo you drink alcohol?*NoYesDo you take any blood thinners?*NoYesALLERGIESDo you have any ALLERGIES?*NoYesIf yes, please list and include the effect/reaction (medication, latex, food & other):*MEDICATIONSAre you taking any medications*including Over-the-Counter Drugs, Puffers, Insulin, Vitamins, or SupplementsNoYesList all MEDICATIONS*including Over-the-Counter Drugs, Puffers, Insulin, Vitamins, or SupplementsPast SurgeriesDo you have any past surgeries?*NoYesPast Surgeries*Please list past surgeries and dates:Consent* By submitting this form, I confirm that my answers are true and have been answered to the best of my ability. Let’s Talk Book Your Consultation Today at 416-360-7-360! Book Appointment