Patient Intake | Ruach Medical Clinic

New patient intake form

Fields marked * are required.

Patient information

Legal first name *Legal last name *Preferred nameDate of birth *Sex assigned at birthGender identityPronounsMarital statusPreferred languageInterpreter needed?

Health card

Optional. You may bring your card to your first visit.

Do you have a health card?Issuing provinceHealth card numberVersion code

Contact information

Street address *City / town *Province *Postal code *Mobile phone *Home phoneEmail address *Preferred contact *Detailed voicemail permitted?

Emergency contact

Full nameRelationshipPhone

Your care today

What brings you to Ruach Medical Clinic? *Current health concernsPrevious family doctorReason for changingPreferred pharmacyPharmacy phone

Medical historyOther conditionsPast surgeries or proceduresPast hospital admissions

Medications and allergiesCurrent medications and dosesAllergiesAllergy reactions

Family historyFamily history details

Lifestyle

Smoking / vapingAlcohol useRecreational substancesOccupationImmunizations up to date?

Privacy and consent

Privacy notice: Ruach Medical Clinic collects this information to assess registration and provide or coordinate care. Access should be limited to authorized staff and handled under applicable Canadian and provincial privacy requirements.

I consent to collection and use of this information for my registration and care. *I consent to being contacted using the details provided. *I confirm this information is accurate and complete. *

Typed signature *Date signed *