Long-term Care Facilities - Canabo Medical Clinic

Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Cell Phone

Email *

DOB

Health Card Number

Other

Is patient taking anti-coagulants?
Is the patient pregnant, or trying to become pregnant?
Does the patient have a significant communicable disease? (HIV, Hepatitis, ect.)
Does the patient have untreated substance abuse/addiction?

Systemic

Specify your Immunological condition

Specify your Neurodegenerative disease

Describe your Cancer

Describe your Other Systemic Issues

Checkboxes

Anxiety/Depression
PTSD
Sleep disorder
Has the Patient been assessed by a Psychiatrist, GP/Psychotherapist or Clinical Psychologist?

Current Medications:

Medications tried for current condition:

Referring Physician or Nurse Practitioner *

Referring Physician Designation: *

Other

Physician Phone *

Fax *

Billing# *

Prac. ID# *

Please attach relevant medical history document here

File types allowed (docx, doc, pdf)

Select a Region *

Please select a clinic in B.C.

Please select a clinic in Ontario

Please select a clinic in Western Canada

Please select a clinic in Atlantic