9 Services 9 Become a Client 9 North Glengarry Client Intake Form

North Glengarry Client Intake Form

Thank you for your interest to become a client of the Glengarry Nurse Practitioner-Led Clinic (GNPLC). The information collected in this form will be used for the purposes of determining your registration eligibility, primary care services/ planning and Ontario Health reporting. The GNPLC collects, uses and discloses personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). Please answer the following questions to the best of your knowledge, so that we may learn more about you and assist in meeting your health care needs. Should you require help completing this form, please request assistance from a person close to you.

Demographics

Name(Required)
Address(Required)
YYYY slash MM slash DD
YYYY slash MM slash DD
Email(Required)
May we leave a message on your phone (i.e to inform you that test results are in, clinic closure or programming)

NOTE: The GNPLC’s target population is to serve those without access to a family doctor or other primary care provider.

Are you currently registered with a Family Doctor or Nurse Practitioner and wish to transfer your care to the GNPLC?

Other health care providers who have been providing you healthcare? Please indicate all that apply

Name & Date of last visit
Name & Date of last visit
Name & Date of last visit
Name & Date of last visit
Name & Date of last visit
YYYY slash MM slash DD
How would you rate your current health status?
Please list ALL current or recent medications (prescriptions, over the counter, vitamins or homeopathic/herbal remedies)
Drug Name
Dose
How Often
Reason
 
Which pharmacy(s) do you obtain your prescriptions from:
Pharmacy name
Location
 
Do you consent to having us contact your pharmacy(s) to obtain an up to date medication listing.

Consent

Consent(Required)

Note: New client registration spots are limited. We will review your form and follow up either by phone or by letter.

See a sample of our QIP 2022-2023 results.

See Results