New Patient Registration Form

New Patient Registration Form
Name *

First Name Last Name
I prefer to be called :
(name)
Date of Birth

Month Day Year
Date
Age
Sex

Male Female N/A
Health Card #
Version Code
Health Card Expiry Date
Address *

Street Address

Street Address Line 2

City Province / State

Postal / Zip Code
Email *
example@example.com
YES! I would like to receive promotional emails or invitations to special events at Dermatology On Bloor.
Home Phone Number *
Cell Phone Number
Occupation
Please indicate how we can contact you during the day (check all that apply):

Email Home Cell
Whom may we thank for referring you?
Referring Doctor/Family Doctor:
Guardian or power of attorney (if applicable) :
If patient 16yrs or younger, does not speak English, or lack capacity, please provide guardian's info:
Home Phone Number
Cell Phone Number
I authorize Derm On Bloor to communicate with my Guardian on my behalf.

Yes
Patient's Signature :
(Your digital signature (full name) is as legally binding as a physical signature.)
Medical History
Current Medications: (prescription, over the counter, vitamins, etc.)
Past Surgeries:
Medical Conditions:
Allergies to Medications, Foods etc:
Do you take Aspirin or blood thinners:

Yes No
Do you have a drug plan:

Yes No
Have you ever had any of the following diseases or medical problems

Asthma Hay fever Eczema Psoriasis Basal Cell Carcinoma Squamous Cell Skin Cancer Melanoma Other Skin Cancer Other Cancer Diabetes High Blood Pressure High Cholesterol Liver Kidney Lung Heart Disease Lupus Rheumatoid Arthritis Multiple Sclerosis Crohn's Disease Ulcerative Colitis Thyroid Disease Vitiligo Alopecia Areata Depression Headaches Seizures Eyes Ears Nose Mouth Blood Clots Bleeding Disorders
Please explain:
Family History:
Please list any diseases that run in your family:
Does anyone in your family have the following (if so, please indicate who):
Social History :
Do you smoke?

Yes No
How many times per day?
Do you use sunscreens?

Yes No
What SPF and which months?
How much alcohol do you drink?
Are you pregnant or planning to become pregnant?
Skin Care Routine :
How often do you shampoo?
How often do you bathe/shower?
How often do you wash your face?
What moisturizers do you use?
Questions About Our Practice
How did you hear of our practice?
If other, please describe
Please check any of our COSMETIC DERMATOLOGY services about which you would like to learn more

Skin Care Products Glycolic Peels / Microdermabrasion Laser Hair Removal BotoxTM Eliminating Facial/Acne Scars Facial Skin Tightening Laser Tattoo Removal Eliminating Leg Veins BotoxTM for Excessive Sweating Removal of Moles/Skin Tags/Cysts Reducing Wrinkles or crepe-paper-like skin Photo-Rejuvenation (Improve Skin Tone/Texture/Colour/Pore size) Body Skin Tightening Restylane/Perlane Juvederm/Voluma Radiesse Sculptra Selphyl
Authorization *

I authorize my physician to release medical information concerning my visit to the referring physicians. In some instances your care may be provided by another physician in the office.
Signature : *
(Your digital signature (full name) is as legally binding as a physical signature.)
Date *

Month Day Year
Should be Empty:

New Patient Registration Form

Medical History