If you wish to save ten minutes when you first visit us, please fill out the patient Intake Form Below.
You may print the form below and fax it to us at (905) 823-2933 or you may bring the completed form with you when you first visit us.
Patient Intake Form
Would you like us to send progress reports to your Family Physician? q Yes q No
Are you pregnant? q Yes q No q Not Applicable
Do you have sensitivity to light? q Yes q No
In your immediate family, is there a history of:
Heart Disease q Yes q No
Arthritis q Yes q No
Cancer q Yes q No
Diabetes q Yes q No
Have you seen any physicians for this condition? q Yes q No
Have you undergone any treatments for this condition? q Yes q No
Are you taking any medications? q Yes q No
How did you hear about us? (Please check all that apply):