Patient Registration Form 1 Acknowledgement2 Personal Information3 Medical History Before your telemedicine appointment, we would like to inform you: A telemedicine appointment is just like a regular doctor’s appointment; except the physician you will see and speak with is on a monitor; A trained healthcare provider will assist you during your telemedicine appointment; he/she will make the connection with the physician at another location; You may withdraw consent to the telemedicine appointment at any time without affecting your right to future care or treatment; A telemedicine appointment with a healthcare provider is available to anyone with a valid Ontario Health Card; This is a service covered by OHIP. If you are not a resident of Ontario, the fee for service is $120 but may be eligible for inter-province compensation with exception for Quebec. Protecting your personal health information is important to us. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Your telemedicine appointment is private and confidential, and it is only seen and heard by the health care provider involved. For more information please visit our website at www.otn.ca or contact the Privacy Officer at firstname.lastname@example.org. It is our clinic policy that no narcotic or controlled substances will be prescribed during walk-in appointments. The same applies to the telemedicine appointments. Please note that NOT ALL conditions can be looked after through telemedicine. You understand that you have the option to seek care at other clinics. I have read and acknowledged the above:Which IDA Walk In Clinic would you prefer to visit?*Market Mall IDA Pharmacy Walk In ClinicIdeal Drugmart Walk In ClinicQueenstown Drug Mart Walk In ClinicConfirmation I have read and acknowledged the above Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleEmail* Family Doctor*YesNoPhysician's NameDo you have an OHIP Number*YesNoOHIP NumberVersion CodeExpiry Date Date Format: MM slash DD slash YYYY Which pharmacy do you currently have your prescriptions filled?*Adel's PharmasaveApothecarium PharmcyCavanagh Pharmacy (Blind River)Central Drug Mart (Pine)Fenlon's Pharmacy (Wawa)Food Basics PharmacyGroup Health Center PharmacyIDA Ideal Wellington EastIDA Market MallIDA Station MallIDA Wellington Square MallMacKav's Island PharmacyJon's Medicine ShoppeMedicine Shoppe Great Northern RoadMedicine Shoppe (Doctor's Building)Medicine Shoppe (Superior Health Team)Metro Churchill PlazaMetro Northern Ave.Merrits PharmacyMitchell Pharmacy (Blind River)Pharma Plus Churchill PlazaPharmasave West EndPrescription Center (Doctor's Building)Rexall East StreetRexall Second LineRexall Trunk/WellingtonRomes/Loblaw's PharmacyShoppers Drug Mart Cambrian MallShoppers Drug Mart Second LineWalMart PharmacyOtherAddress* Street Address Apt # City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred Daytime Phone*Home PhoneWork PhoneCell PhoneEmergency Contact First Last Emergency Contact RelationshipEmergency Contact Phone Reason for your visit*Allergies*Height (cm)Weight (lbs)Please tell us about your health history. Please answer the questions below and provide us with any further information in the text boxes below: Smoker*YesNoAsthma*YesNoHeart Disease*YesNoHigh Blood Pressure*YesNoCancer*YesNoStomach Problems*YesNoDiabetes*YesNoHigh Cholesterol*YesNoThyroid Problems*YesNoFrequent Headaches*YesNoArthritis*YesNoBowel Problems*YesNoKidney Problems*YesNoSkin Conditions*YesNoRecent Surgery*YesNoPlease provide the name of any illness or condition associated with the answers above. Please also provide the name of any medication and/or treatmentPlease describe any past surgeriesCurrent Prescription, non-prescription medications and herbal productsOur pharmacists assist the doctor in gathering the history and will be speaking with youPhoneThis field is for validation purposes and should be left unchanged.