Home > test form Meet Doctor Plant Home > test form Historical Patient Intake First Name*Middle NameLast Name*OHIP Number Including Version Code*Family Physician*Birth Date* Date Format: MM slash DD slash YYYY Age*Height*Weight*Gender*GenderFemaleMalePrefer Not To SayStreet Address*Address Line 2City*Province*ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Phone Number*Email* May We Communicate With You Over Email?*May We Communicate With You Over Email?YesNoMay We Include You In On Our Email List?*May We Include You In On Our Email List?YesNoHow Did You Hear About Dr. Plant?Have Friends or Family Seen Dr. Plant?Do you have any pre existing conditions?Do You Have Any Of The Following Conditions?* Heart Problems Diabetes Hepatitis / Jaundice Asthma Other None Do you Have Any Other Health Conditions?Do You Take Any Medications, Vitamins, or Supplements?Do You Take Any Medications, Vitamins, or Supplements?YesNoDo You Take Any Blood Thinners?*Do You Take Any Blood Thinners?YesNoHave You Had Any Past Operations?*Have You Had Any Past Operations?YesNoDo You Have Any Allergies?*Do You Have Any Allergies?YesNoDo You Smoke?*Do You Smoke?YesNoDo You Drink Alcohol?*Do You Drink Alcohol?YesNoConsent* I Certify That I Am The Patient And The Information Included In Here Is TrueToday's Date* Date Format: MM slash DD slash YYYY Upload Files* Drop files here or Accepted file types: jpg, gif, png, pdf, jpeg, heic. Please upload the requested photographs using this link. You may also use it to provide any other documents you feel may be relevant to your consultation including additional photographs or records from previous procedures. Files Uploaded
