New Patient Application Form Medview Medical Clinic New Patient Application Form First & Last Name City of Residence Date of Birth/Age Email Address Phone Number Alternative Phone Number Do you currently have a Family Doctor? Yes No If yes, What is the name of your Family Doctor? What is the reason to switch doctors? If you are applying as a family, please fill out their information in the following box (separated by comma) Do you currently take Any narcotics? (i/e controlled substances: Morphine, Hydromorphone, Tramadol, etc)... Yes No Do you currently take Any Recreational drugs? Yes No Do you have or ever had an ICBC claim(s)? Do you have or ever had an WBC claim(s)? Please be advised that we are unable to accept new patients who are actively looking to obtain medical leave from work or schools. I (We) agree I (We) disagree NO SHOW/ LATE VISIT POLICY: In order to serve our patients better and minimize disruptions in the flow of work at this clinic, we enforce $ 75.00 fee for missed appointment without proper 24 hours notice. I (We) agree I (We) disagree CONSENT TO PHYISCIANS FOR ACCESS TO YOUR MEDICAL INFORMATION : Physicians often need to review medical information of patients on different platforms e.g. Pharmanet and Care Connects for providing the best practice. Please indicate your choice from the drop box: I (We) agree I (We) disagree I hereby certify that the information provided here is accurate and true. I also declare that I understand the content of this form. Yes Today's Date Your Name Submit Application
