SUSPENDED FORM

452 Borland Street, Williams Lake, BC, V2G 1R7
Tel: 250-392-1971

Welcome!

Borland Medi-Clinic aims to be 98% paperless and therefore we have decided to go the extra mile and secure an online registration form. The information entered into this form is 100% safe and will only be used by Borland Medi-Clinic to create and update your electronic medical record.

The information requested in this form is designed to help the physicians working in Borland Medi-Clinic to make better decisions for you.

Personal Information:

Applicant

Name:

Healthcare Number:

Date of birth:

Email:
We will be sending important results in a encrypted format to this e-mail address.

Address

Occupation:

Family Doctor:
Williams Lake

Other:
Write the name of your family physician in the space provided. We like to keep them informed.

Preferred Pharmacy:
Please note town if registering from out of Williams Lake.

Contact Information:

Cell Phone:

Home Phone:

Work Phone:

Primary Phone:
Where you want us to reach you first.

Other:

Medical History:

Please mark any past medical conditions you have been diagnosed with before or currently receive treatment for:

Cardiovascular

High blood pressure‎ Heart Attack‎ Heart Failure‎ Atrial Fibrillation‎ Heart Valve Disease‎ High Cholesterol‎ Blood clots in lungs or legs‎ Poor circulation in legs‎ Other heart/blood vessel disease‎

Other:
Type other conditions in the space provided.

Respiratory

Asthma‎ COPD/Emphysema/Chronic Bronchitis‎ Recurrent Lung infections‎ Sleep Apnea‎ Lung Cancer‎ Other lung disease‎

Other:
Type other conditions in the space provided.

GI

GERD/Acid Reflux‎ Stomach Ulcers‎ Crohn's Disease‎ Colitis‎ Celiac's Disease‎ Diverticulosis/Diverticulitis‎ Irritable bowel syndrome‎ Colon Cancer‎ Liver Cirrhosis‎ Hepatitis C‎ Gallstones‎ Liver Disease‎ Pancreatitis‎ Other stomach, bowel, liver or pancreas problems‎

Other:
Type other conditions in the space provided.

Uro-Genital

Kidney Stones‎ Kidney Failure‎ Kidney Disease‎ Recurrent Bladder Infections‎ Bladder Cancer‎ Prostate Cancer‎ Enlarged Prostate (BPH)‎ Other bladder or kidney disease‎

Other:
Type other conditions in the space provided.

Endocrine

Diabetes Mellitus‎ Thyroid Disease‎ Other hormone problems‎

Other:
Type other conditions in the space provided.

Neurology

Seizures / Epilepsy‎ Stroke/CVA/TIA‎ Brain Injury‎ Neuropathy‎ Migraines‎ Chronic Headaches‎ Parkinsons‎ Multiple Sclerosis‎ Other nerve/brain disease‎

Other:
Type other conditions in the space provided.

Eye disease

Glaucoma‎ Cataracts‎ Other eye disease‎

Other:
Type other conditions in the space provided.

Blood disorders

Anemia‎ Leukemia‎ Lymphoma‎ HIV/AIDS‎ Low Platelet counts‎ Hemochromatosis‎ Bone Marrow problems‎ Other blood/bone marrow‎

Other:
Type other conditions in the space provided.

Ear Nose and Throat

Hearing difficulties‎ Vertigo‎ Recurrent ear infections‎

Other:
Type other conditions in the space provided.

Skin Conditions

Psoriasis‎ Eczema‎ Leg/Foot ulcers‎ Other skin disease‎

Other:
Type other conditions in the space provided.

Joints

Osteoarthritis‎ Rheumatoid Arthritis‎ SLE (lupus)‎ Gout‎ Osteoporosis‎ Chronic/ recurrent back pain‎ Chronic/recurrent neck pain‎ Fibromyalgia‎ Other joint/ bone disease‎

Other:
Type other conditions in the space provided.

Gynecology

Endometriosis‎ Uterus Fibroids‎ Heavy/Painful menstruations‎ Menopause‎ Ovarian Cysts‎ Infertility‎ Sexual Transmitted diseases‎

How many times have you been pregnant?

How many children did you have?

How many miscarriages did you have?

How many times have you had a termination of pregnancy (abortion)?

Mental Illness

Depression‎ Anxiety‎ Obsessive Compulsive Disorder (OCD)‎ Bipolar Mood Disorder‎ Borderline Personality Disorder‎ Schizophrenia‎ Nervous Break Down‎ Other mental health problems‎

Other
Mental Health

Surgeries
Type nil of no allergies

Allergies
Type nil if no allergies

Medication:
Type nil if no medication

Patient Consent to Access PharmaNet:

The Province of British Columbia has established the provincial computerized pharmacy network and database known as "PharmNet" pursuant to section 37 of the Pharmacists, Pharmacy and Drug Scheduling Act, R.S.B.C. 1996, c. 363, and which may be continued pursuant to section 13 of the Pharmacy Operations and Drug Scheduling Act, S.B.C, 2003, c.77 should it be proclaimed in force during the term of this Agreement.

I authorize all the physicians of the Borland Medi-Clinic and persons directly supervised by them to access my personal health information contained within PharmaNet for the purpose of providing therapeutic treatment or care to me, or for the purpose of monitoring drug use by me. I understand that withdrawal of this consent must be in writing and delivered to the physicians of the Borland Medi-Clinic.

Consent

I confirm that I understand and have read the Privacy Policy of Borland Medi-Clinic. I confirm that the information shared in this registration form is true and correct to the best of my knowledge.

I have read and agree to the above consent.

Yes No

Electronic signature

Clear

Verification

Powered by 123FormBuilder Report abuse