Profile Imformation - Step 1 of 3

You are completing the intake form: Intake form (September 2023) for **

Please take a moment to fill out our online intake form before you visit.All information is kept completely confidential.

Only Stoff members can edit this informatjon on on intake form.

First Name -Required

Last Name -Required

Preffered Name (if different)

Pronouns

Prefix / Title

Emqail -Required

Please provide at least one phone number. Your mobile number can be used to look up your Account and receive text message appointment reminders.

Mobile Phone

CA (

A mobile phone is required if you would like to receive SMS appointment reminders.

Home Phone

CA (

Country

City

Province

Postal / Zip

Date of Birth -Required

Gender

Refers to current gender which may be different than what is indicated on your insurance policies or medical record.

Sex

This field may be used for submitting claims to your insurance provider. Please ensure the sex you provide here matches what your insurance provider has on file or what is indicated on your medical record.

Personal Health Number -Required

Guardian

Emergency Contact

Emergency Contact Phone

Emergency Contact Relationship

Family Doctor -Required

Family Doctor Phone (if known)

Family Doctor Email (if known)

Referring Professional

Referring Professional Phone (if known)

Referring Professional Email (if known)

How did you hear about us?

Who were you freffered to?

Insurance Imformation - Step 2 of 3

You are completing the following intake forms: Intake form (September 2023)

Your insurance policy

Insurer

Consents - Step 3 of 3

You are completing the following intake forms: Intake form (September 2023) Communication

Appointment Notifications and Reminders

You can opt to receive emails to keep you informed of new bookings, changes to your bookings, and reminders for upcoming appointments.

Email 24 hours before appointment

Text message (SMS)

Standard messaging & data rates may apply, messaging frequency can vary and you can update your preferences anytime.

Text Message (SMS) 24 hours before appointment

Phone call

Phone Call 24 hours before appointment

News and Special Promotions

Yes, I would like to receive news and special promotions by email

Signature

Draw

Type