IHAC Application for Services

Medical Information
Present General Practioner

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Last Appointment
Present Dentist

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Current Medications
Please list any current medications, dosage, time of administration and for what reason.
Prescribing Doctor
Prescribing Doctor of Medication
Phone Number
Allergies
Describe any known Allergies
Smoker

Yes No
Alcohol Use

None Known Occasionally Frequently
Drug Use Current/History
Describe current or historic drug use and drug of choice
Current On-going Medical Concerns
Previous Conditions That Required Regular Doctor Visits
Previous Conditions that Required Hospitalization
if applicable please include dates
Past Surgeries
if applicable please include dates

Application for Services