Waitlist form

[email protected]

Home
About Us
Doctors
Services
Patient Resources
Contact
FAQ’s

Call US

New Patient Intake Form

Waitlist

First Name *

Last Name *

Gender *

Date of Birth *

Alberta Health Card Number *

please ensure you type the 9 digits on the health card

Home Phone

Cell Phone *

Address *

City

Province

Postal

Pre-existing medical conditions *

Angina / Coronary artery disease / previous heart attack

Heart Failure

High blood pressure

Heart murmur / heart valve problems

Chronic Pain

CVA / Stroke

Parkinson’s Disease

Depression

Bipolar Disorder

Other Psychiatric condition

Ulcerative Colitis

Coeliac Disease ( gluten allergy)

Liver Cirrhosis

I have had problems with Drug Misuse

Other medical condition

Atrial Fibrillation

Diabetes

COPD ( Chronic obstructive pulmonary Disease)

Asthma

Epilepsy

TIA / mini-stroke

Arthritis

Anxiety

Personality Disorder

Schizophrenia

Crohn’s disease

Gastroesophageal reflux disorder

I am a smoker

I have had problems with Alcohol Misuse

No pre-existing medical condition

Please be advised that this list is just to help the doctor understand your needs in preparation for your first appointment. NO patient will be turned down based on their pre-existing health conditions.

Additional medical notes

Any previous surgery?

Please list any previous surgery with date

Significant Family History

Are you prescribed any opioids? *

Yes

List Opioids and dosages *

Current medications & dosage *

Allergies

Immunizations

Type immunization along with the date if known

Screening

Social background

Please write the name of the family doctor you would like to register on the waitlist for ( current waitlist times 4-5 months)

Emergency contact or next of kin name *

Emergency Contact Phone *

Relationship

How did you hear about us? *

Asperia Medical Clinic will contact you by email to send you:

Appointment bookings and reminders

Referral bookings

General information about our office and clinics

Certain test results if your doctor has specifically discussed and agreed to this option

• Please tell us which email address you wish us to use. Don’t forget to inform us of any changes to your email address.

• If you intend to receive our emails, please remember to update your address book with the following and/or to check your junk/spam folder. *

[email protected]

• There are some privacy risks in using email: *

Email is not secure. While we try to protect our emails we cannot guarantee the security and confidentiality of any email you receive from us. As the message leaves Asperia Medical Clinic, it is sent across the internet and it could be intercepted and read.

Emails we send to you may be filed on your health record depending on the email message and can become a permanent part of your health record. Emails can be used as evidence in court.

Email is easy to forge, easy to forward (sometimes accidentally and to many people) and may exist forever.

If you use a work email, your employer may have a right to archive and inspect emails sent from their systems. We recommend you avoid using a work email address.

Asperia Medical Clinic is not responsible for information loss due to technical failures

Virtual Care Policy & Consent *

I understand and accept the risks related to unauthorized disclosure or interception of personal health information via virtual medicine, and know that I need to be in a private setting using my own computer/device.

I know that : *

• Email should never be used in an emergency. If you have an emergency, you should call 9-1-1 or go to your nearest hospital emergency room or health care provider immediately.

• Email should never be used for urgent problems (where you need a response from us by a certain time). If you have an urgent issue, you should call the office and make an appointment to see your Asperia Medical Clinic health care provider.

Patient Acknowledgment, Agreement and Release: * *

The Patient agrees to treat all Clinic staff, other patients, and visitors with respect and courtesy.

The Patient agrees not to engage in any behavior that is threatening, abusive, or harassing towards Clinic staff or others present in the Clinic

The Patient understands that repeated missed appointments or late cancellations may result in a fee, as determined by the Clinic.

The Patient agrees to provide advance notice of cancellation if they are unable to attend a scheduled appointment.

The Patient agrees to pay for all uninsured services prior to receiving the service.

The Patient acknowledges that not all services provided by the Clinic are covered by the Alberta Health Care Insurance Plan.

The Patient agrees to comply with all Clinic policies and procedures, including those related to appointment scheduling, payment, and confidentiality.

The Patient agrees to follow the instructions and recommendations provided by Clinic staff regarding their care and treatment.

The Patient agrees not to consume alcohol or illegal drugs on Clinic premises.

The Patient agrees not to attend appointments while under the influence of alcohol or illegal drugs.

In the event of a disagreement or conflict with Clinic staff or other patients, the Patient agrees to address the issue in a constructive and respectful manner.

The Patient agrees to refrain from disruptive behavior or causing disturbances within the Clinic premises.

The Patient agrees to respect the confidentiality of other patients and Clinic staff and not to disclose any confidential information obtained during their visits to the Clinic.

The Patient agrees to comply with any safety and security protocols implemented by the Clinic, including those related to emergency procedures and evacuation plans.

The Patient understands that failure to comply with the terms of this Agreement may result in disciplinary action, including termination of treatment at the Clinic.

• I understand the risks associated with using email with Asperia Medical Clinic and I accept those risks.

• I understand the limits set out for using email with Asperia Medical Clinic and I agree to follow those limits.

• I understand if I no longer wish to receive Asperia Medical Clinic emails, I will write to [email protected]

• RELEASE OF LIABILITY: I agree that Asperia Medical Clinic (and their physicians, staff, agents and officers) shall not be responsible for any personal injury including death, and/or privacy breach (outside the control of Asperia Medical Clinic ) or other damages as a result of my choice to receive emails from the Asperia Medical Clinic and I release the Asperia Medical Clinic (and their physicians, staff, agents and officers) from any liability relating to communicating with me by email.

• I understand that Asperia Medical Clinic may choose not to deal with me by email if I am not able to follow the email rules or if the Asperia Medical Clinic changes its email program.

• If I had any questions about this form, I have Asperia Medical Clinic those questions and agree that my questions have been answered.

• I have read and fully understand this consent and release form.

• I understand I have the right to have legal advice about signing this form and what it means to me and I have either sought that advice or chosen not to seek such advice.

By signing below, the Patient acknowledges that they have read and understand the terms of this Agreement and agree to adhere to its provisions.

Signature

Clear

If you are human, leave this field blank.

Waitlist form

[email protected]

New Patient Intake Form

Your Health, Our Priorty  Compassionate Care Exceptional Results

Our Services

Contact Us

Accepting new patients

Copyright © Asperia Medical Clinic 2024. All rights reserved

[email protected]

New Patient Intake Form

Your Health, Our Priorty Compassionate Care Exceptional Results

Our Services

Contact Us

Accepting new patients

Copyright © Asperia Medical Clinic 2024. All rights reserved

Your Health, Our Priorty  Compassionate Care Exceptional Results