Walk-in Clinic and Pharmacy
(204) 282-6699
(204) 943-5495
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Date of Birth
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Day Time Phone Number
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Work Phone Number
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PHIN
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Your Personal Health ID Number (9 Digits)
MHSC
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Emergency Contact Name
In the case of Emergency, who should we contact?
Relationship
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Do you have a Family Doctor
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If YES, what is your Family Doctor's Name?
Why are you wanting to switch doctors?
Past Medical History
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Family Medical History
Allergies
List Any Medication You Are Currently Taking
Dosage Of Medication
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Are You On Any Narcotic/Controlled Medication Regularly?
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If Yes, Which Medication
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Pharmacy Contact Name:
Pharmacy Contact Address:
Other Information
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Please Note:
This form is for information purpose only and not an agreement to becoming a new patient for a doctor. Any omission of information for falsifying information may lead to immediate rejections. You will be contacted by phone if accepted to schedule a first visit appointment.
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(204) 282 - 6699