Required Patient Summary

Application Form 

This Confidential* Patient Summary application form is essential for the physician to understand your unique medical history and current needs.  Only those who fully complete this form can be considered for consultation.  This is another step to ensure the best possible result from your medical review.  We will verify your personal and physician contact information.  Only those persons with a published home phone number and an ISP email address can be considered (not alias/vanity addresses like Hotmail).  This review must be completed every 12 months to keep current with your changing health needs.

Please provide the following contact information.

All information except Work Phone  is required.

About You
Your First Name
Your Last Name
Street Number
Street Name
Suite / Apt # 
City
State/Province
Zip/Postal Code
Country
Work Phone Area Code
Work Phone
Home Phone Area Code
Home Phone
Year Of Birth (e.g. 1950) 
Sex
Weight  (specify lbs. or kgs.)  
Height  (specify feet/inches e.g. 5/10. or cm.)  
Your base E-mail address 

(not Hotmail or another alias email address.)
About Your Pharmacy
Your Pharmacy Name
Your Pharmacy's Phone Area Code
Your Pharmacy's Number
Your Pharmacy's FAX
About Your Doctor
Your Dr.'s First Name
Your Dr.'s Last Name
Your Dr.'s Address
Your Doctor's City
Your Doctor's State/Province
Your Dr.'s Phone Area Code
Your Dr.'s Phone Number
Your Dr.'s FAX

I am 18 years of age or older.

I agree to become a Patient of Ontario for the purpose of this or other medical consultations and agree to be bound by the rules and regulations and laws governing this. 

I have read and agree to the Terms & Conditions found in the Legal section of this website.

Are you pregnant? 

Are you nursing?    

I understand that if approved, I will be charged a non-refundable fee of US$40 / CDN$50 to participate in this program.  This fee is will be credited toward a future consultation or prescription review requested by me in the next 12 months.

Check off any of the medications you take:

Coumadin or Warfarin
Heparin
Asperin
Non-steroidal-anti-inflammatories (NSAIDS) e.g.. Naprosyn, Vioxx, Celebrex
Heart Medication
Seizure Medication
Blood Pressure Medication
Cancer Medication or Chemotherapy

List the prescription medication that your doctor (s) have prescribed:

List the over-the-counter (OTC) medication that you take regularly:


Do you suffer from any of the following PAIN conditions?:

Osteoarthritis
Rheumatoid Arthritis
Any other Arthritis
Fibromyalgia
Myofascial Pain Syndrome
Tendonitis
Bursitis
Back pain
Neck Pain
Degenerative Spinal Disease
Herniated Disk
Carpal Tunnel Syndrome
Patellofemoral Syndrome
Temporomandibular Joint Disease or TMJ
Rotator Cuff Injury
Repetitive Strain Injury

Have you ever suffered from any of the following MEDICAL conditions?

Heart Disease
High Blood Pressure or Hypertension
Migraine Headache
Arthritis (any kind)
Cancer
Anemia
Asthma
Emphysema
Lung disease
Male or Female Fertility Problems
Chronic Pain (any kind)
Depression
Suicidal
Hallucinations or Delusions
Peptic Ulcer Disease
Irritable Bowel Syndrome
Inflammatory Bowel Disease (Crohn's Disease, Colitis)
Kidney Disease or Failure
Diabetes
Liver Disease
Hepatitis (any kind)
Drug or Alcohol Addiction
Chronic Skin Disease or Open Sores
Chronic Penile or Vaginal Discharge
Chronic Infections (any kind)
Glaucoma or other Eye Disease
Bleeding Disorder
Chronic Nose Bleeds, Rectal Bleeding, Blood in Urine

List all of your allergies:


List all of your operations or other reasons for hospital visits:


List all of your pain problems:


Anything else you want the doctor to know?


For those choosing telephone consultations, what do you want to discuss with the doctor?


Type Your First & Last Name To Confirm Agreement.