Long-term Care Facilities - Canabo Medical Clinic

Name *

Address *

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City

State / Province / Region

Postal Code

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Home Phone

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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)

Please select a clinic location *