Patient Information & OHIP Registration Form

Personal Information

Full Name

Date of Birth

Gender

Male

Female

Other

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Emergency Contact

Name

Relationship

Phone Number

OHIP Registration

OHIP Number

Health Card Version Code

Expiry Date

Effective Date

Medical History

Primary Care Physician

Preferred Pharmacy

Current Medications

Previous Surgeries

Allergies

Chronic Conditions

Symptoms

Main Concern/Reason for Visit

Symptoms

Frequency of Symptoms

Alleviating Factors

Onset of Symptoms

Triggers or Aggravating Factors

Previous Episodes

Changes in Lifestyle

Medication History

Sleep Patterns

Dietary Habits

Allergies

Fever

Recent Travel or Exposures

Severity Scale (1-10)

Impact on Daily Activities

Additional Comments

Lifestyle

Family History

Family History of Medical Conditions

Insurance Information

Some description about this section

Insurance Provider

Policy Number

Group Number

Subscriber Name

Subscriber Date of Birth

Consent

I,, hereby provide consent for the evaluation of my ailment by a qualified medical professional at Just Walk In Medical Clinic . I understand that the assessment will be conducted by a trained medical assistant or qualified doctor, and all information shared during this process will be kept confidential. I retain the right to ask questions about the evaluation and proposed treatments, and I am aware of my right to explore alternative healthcare options. I willingly consent to the evaluation under these terms.

Patient's Full Name

Signature

Date