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Phoenix Medical Centre
Phoenix Medical Centre Patient Intake Form
PATIENT INTAKE FORM
First name
*
Last name
*
Birthday
Year
Month
Month
Day
Gender
Male
Female
Other
Ontario Health Card Number
*
Address
Phone
*
Email
*
Message
*
Emergency Contact
Full Name
*
Relationship
*
Phone
Medical History
Primary Care Physician
*
Primary Care Physician Phone Number
Do you have any chronic conditions / illnesses
Yes
No
If Yes, Please list
Are you currently taking any medications?
*
Yes
No
If yes, Please list
Do you have any known allergies
Yes
No
If yes, Please list
Have you undergone any recent surgeries or hospitalizations?
Yes
No
If yes, Please describe
Have you had any recent illnesses or symptoms?
Yes
No
If yes, Please describe
Reason For Consultations
Primary Concern or Problem
When did this issue start?
Have you received any treatment for this issue? If yes, please describe
Do you consent to receive medical services via Virtual / Telemedicine?
Yes
No
Date Form Was Completed
Year
Month
Month
Day
Submit
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About Us
Dr Sheldon Heshkop
Dr Maurice Siu
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Platelet - Rich Plasma & Exosomes
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Medical Intake Form
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