Name: Express Medical Care
Price range: $

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Please complete this form to register as a patient. If you would like to speak with us on the phone, do not hesitate to call us at 204‑306‑4259. Know more about our doctors.

Patient Demographics

Name:

Date of Birth (MM/DD/YY):

Email address:

PHIN# (9 digits):

MHC# (6 digits):

Gender:

Any ALLERGIES, specify:

Address:

Home Phone:

Cell Phone (required):

Can we leave messages on your preferred phone number?
Yes, any messages Appointment information only No messages

How did you hear about us?

Preferred Pharmacy

Name:

Address:

Tel:

Fax:

Emergency Contact

Name:

Relationship to you:

Tel:

Social History

Country of Origin:

Language Spoken:

Occupation:

Marital Status:

Spouse/Partner's Name:

Medical History

Name of Previous Family Physician:

Clinic Name:

Clinic Location:

Do you smoke cigarettes?
Yes No

If YES, how many do you smoke per day?

If No, did you ever previously smoke cigarettes?
Yes No

When did you quit?

How many alcoholic beverages, if any, do you drink per week?

Pertinent Medical History

Previous Hospitalization/Surgeries

Family History Of Medical Illness

Social History
Medications: All Prescribed Medications and Over the Counter (OTC) Medications

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