Intake ArfinnMed

Contact Information

Your Name*

Home Phone

Cell Phone*

Email*

Address*

Address Line 2

City*

State*

Zipcode*

County*

Patient Information

Sex*

Gender

Please select if this is different from sex.

Specify Gender

Your Date of Birth (DOB)*

Height (Feet)*

Height (Inches)*

Weight (lbs)*

Social Security

Last 4 of Social Security

Province Health Insurance Plan ID Upload*

Please upload a photo or a scan of your Province Health Insurance Plan ID

Identification Documents

Drivers License #

In which state is your drivers license

Drivers License Photo/Upload

Please upload a photo or scan of your driver's license.

Medical Record Diagnosis

Please upload a photo or scan of your Medical Record Diagnosis.

Emergency Contact

Emergency Contact Name

Emergency Contact's Phone #

Primary Care Physician

Primary Care Physician Name

Primary Care Physician Phone #

Guardian Information

If the patient is a minor, please fill out the following information.

Father's Name

Father's Phone #

Mother's Name

Mother's Phone #

Caregiver's Name

Caregiver's Phone #

Current Condition

If known, please tell us which condition are you currently seeking treatment for.

Qualifying Condition

Cancer Type

Identify Terminal Illness

Identify Pain Type

Describe Qualifying Condition

Describe the problem you would like addressed and when it started.*

Have you treated this problem before? How and when?*

Please list all illnesses and/or hospitalizations/surgeries you have had in the past*

Please list the name and dose of any current medication and/or additional supplements and vitamins you are taking*

Please list any family history of disease*

Please list all known allergies*

Do you currently use tobacco?*

Have you used tobacco in the past?*

Do you currently use recreational drugs?*

Are you currently pregnant?*

Do you exercise regularly?

How many hours of sleep do you get at night?

Rate your diet

Please select any symptoms/conditions you currently have

Signature*

Patient Access Code

Phone

This field is for validation purposes and should be left unchanged.

New Patient Intake Form | Donald Turner