First time visitor must fill in this form.
Our clinic staff member will call you to set your appointment.

Returning visitor must call +1 (705) 503-5300 to speak
with office administrator to set an appointment.

    Your Name*

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    Address *

    Date of Birth*

    Health Card*

    Past History*

    Current Medications*

    Allergies *

    Family History *

    Hospitalizations*

    Smoker*
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    Alcohol Use *
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    Additional Comments