Phone




Next of Kin










Emergency Contact






















AsthmaDiabetes Type 1 / Type 2Heart Attack (MI)Stroke/CVAPacemakerDVTEmphysemaDepression and/or AnxietyCancer (type)HIV/AIDSHepatitis A/B/CEpilepsyOther (please list)

List Family Medical Histories

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.

I consent to my health record being reviewed as a part of the quality improvement activities in this practice.

YesNo

I consent to my healthcare information being uploaded to My eHealth Record

YesNo

Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.

I consent to being contacted with reminders.

YesNo

I consent to being contacted by email.

YesNo