Patient Intake Form

PATIENT INFORMATION

First Name*

Middle Name

Last Name*

Gender*

Female
Male
Gender Neutral

Date of Birth*

Age*

Phone Number*

(you can be reached)

Health Number*

Health Number Version*

One / Two Right Side Letters

Family Physician*

Address

Street Address*

Address Line 2

City*

Province*

Postal 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 INTEREST

Treatments 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 360

Other Treatments of Interest

HEALTH INFORMATION

Do you have any of these conditions?

Heart Problems
Diabetes
Hepatitis / Jaundice
Asthma

Other Health Conditions

Do you smoke?*

No
Yes

Do you drink alcohol?*

No
Yes

Do you take any blood thinners?*

No
Yes

ALLERGIES

Do you have any ALLERGIES?*

No
Yes

If yes, please list and include the effect/reaction (medication, latex, food & other):*

MEDICATIONS

Are 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 Supplements

Past Surgeries

Do 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.