New Patient Intake

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Patient Informaton

Patient Last Name

Patient First Name

Date of Birth

Phone Number

Gender

Personal Health Number (PHN)

10 Digital Number

Medical Provider

下拉

Important Notice

Before completing this intake form, please ensure that you have registered your information with the Health Connect Registry of the Government of British Columbia at the following link:
https://www.healthlinkbc.ca/find-care/health-connect-registry

If you have not completed this registration, your intake form will not be considered valid, and our providers will not be able to accept you as a new patient.

CODE OF CONDUCT AND PRACTICE POLICIES

Code of Conduct: We provide care regardless of religious affiliation, race, gender identity, or socioeconomic position. We expect respect for all team members and have a zero-tolerance policy for harassment or violence. Any such acts will result in immediate termination of the therapeutic relationship.
Appointments: Please arrive 5 minutes early. To ensure high-quality care, we may only address 1-2 items per visit.

Late Policy: Arriving more than 30 minutes late without notification may be subject to the no-show policy.
Cancellations: Must be made at least 24 hours prior to the start time.
No-Show Policy: You will be charged a up to $95 fee. No further appointments can be booked until this is paid in full.

Prescription Renewals: We do not routinely renew prescriptions by fax or phone. Please book a follow-up visit before your medication runs out.
Vaccinations: Fresh Bay Medical Centre advocates for routine childhood and adult vaccinations. To protect immunocompromised patients, if you do not follow routine vaccination schedules, we kindly ask you to consider another clinic.
Uninsured Services: Services not covered by MSP (sick notes, forms, cosmetic procedures, etc.) will be subject to fees.
We will discuss 1-2 issues each visit based on limited appointment time. Please prioritize your questions.
I consent to the clinic communicating with me and sending health-related information via electronic means, including email, SMS (text messaging), and fax. I understand that such communication may carry privacy risks and cannot be guaranteed to be fully secure.I accept these risks and authorize the clinic to use these methods for appointment reminders, test results, and other healthcare-related communications.I understand that I may withdraw or modify this consent at any time by providing written notice.
Termination of Relationship: Termination may occur due to harassment, excessive use of outside clinics, routine lateness, or a significant breakdown in the physician-patient relationship.

Signing

Birth Phone Email

By this document, you declare you have read it in its entirety and agree to abide by the Code of Conduct and Practice Policies of Fresh Bay Medical Centre.

Date Of Signing:

Printed Name:

Signature

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