PATIENT INTRODUCTION FORM - NS Wellness 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling in your LAST name, FIRST initial, and ADDRESS. Ensure accuracy for effective communication.
  3. Provide your spouse’s name, CITY, POSTAL CODE, and the NUMBER of children. This information helps us understand your family context.
  4. Enter your TELEPHONE numbers (Home, Work, Cell) and select your SEX and MARITAL STATUS from the options provided.
  5. Fill in your EMAIL address, DATE OF BIRTH, and AGE. This data is crucial for patient records.
  6. List your FAMILY PHYSICIAN's name and contact number. This assists in coordinating care effectively.
  7. Indicate if you have a B.C. CARECARD and answer questions regarding pregnancy or insurance claims as applicable.
  8. Detail the REASON FOR VISIT and any pain characteristics. Be specific to help us tailor your treatment plan.
  9. Complete sections on past medical history, surgeries, medications, and consent at the end of the form before submitting.

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