PATIENT INTAKE FORM

Name(Required)
Date of Birth(Required)
Email(Required)
Address(Required)
Are you currently registered with Health Care Connect?(Required)

Have you ever been diagnosed with the following:

High Blood Preasure(Required)
STROKE(Required)
HEART ATTACK(Required)
HIGH CHOLESTEROL(Required)
DIABETES(Required)
DEPRESSION(Required)
ANXIETY(Required)
FIBROMYALGIA(Required)
CHRONIC PAIN(Required)
THYROID PROBLEMS(Required)
ASTHMA(Required)
COPD(Required)
SKIN CONDITIONS(Required)
CANCER(Required)

620 Arthur St. West Thunder Bay, ON