Patient Information & OHIP Registration Form Patient Information & OHIP Registration FormPersonal InformationFull NameDate of BirthGender Male Female OtherAddressAddress Line 1Address Line 2CityStateZip CodePhone NumberEmailEmergency ContactNameRelationshipPhone NumberOHIP RegistrationOHIP NumberHealth Card Version CodeExpiry DateEffective DateMedical HistoryPrimary Care PhysicianPreferred PharmacyCurrent MedicationsPrevious SurgeriesAllergiesChronic ConditionsSymptomsMain Concern/Reason for VisitSymptomsFrequency of SymptomsAlleviating FactorsOnset of SymptomsTriggers or Aggravating FactorsPrevious EpisodesChanges in LifestyleMedication HistorySleep PatternsDietary HabitsAllergiesFeverRecent Travel or ExposuresSeverity Scale (1-10)Impact on Daily ActivitiesAdditional CommentsLifestyleSmoking Status Non-smoker Former smoker Current smokerAlcohol Consumption Never Occasionally RegularlyPhysical Activity Sedentary Light exercise Moderate exercise Intense exerciseFamily HistoryFamily History of Medical ConditionsInsurance InformationSome description about this sectionInsurance ProviderPolicy NumberGroup NumberSubscriber NameSubscriber Date of BirthConsentI,, 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 NameSignatureDateSubmit Form
