Patient Intake Form PATIENT INFORMATIONFirst Name* Middle Name Last Name* Gender* Female Male Gender Neutral Date of Birth* YYYY slash MM slash DD Age* Phone Number* (you can be reached)AddressStreet Address* Address Line 2 City* Province*OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukonPostal Code* OHIP* OHIP Version* One / Two Right Side LettersFamily Physician* Other Health Cards / Old OHIP Card Other Health Cards / Old OHIP Card Health Number* 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?* No Yes Do you drink alcohol?* No Yes Do you take any blood thinners?* No Yes ALLERGIESDo you have any ALLERGIES?* No Yes If 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 Supplements No Yes List all MEDICATIONS*including Over-the-Counter Drugs, Puffers, Insulin, Vitamins, or SupplementsPast SurgeriesDo you have any past surgeries?* No Yes Past 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. NameThis field is for validation purposes and should be left unchanged.
