REGISTRATION FORM   

Name:____________________________________________________________  GENDER:        Male       Female

LAST                                  First                                         middle

Birthdate: (m/d/y)_­­­­­­_________________ Health Care #:____________________________Prov. _______

Home Address: _____________________________________________________________________________

City/Province: ______________________________________________Postal Code: _______________

Phone Number: CELL:______________________ Bus: _____________________ Home : _____________________

Occupation: _____________________________________ Email_________________________________________   □ YES, I would like email APPOINTMENT REMINDERS

EMERGENCY Contact______________________ Relationship & Ph #_____________________________

Referred by Dr._________________________________Family Doctor: _________________________________                                 

MEDICATION + Vitamins:   ___________________________________________________________________________________________________________

ALLERGIES: ____________________________________________________________________________________

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY

 ____PO           ____POSITIVE for HIV/AIDS                          ____On Blood thinners/ Bleeding Tendency

       ____ Hepatitis A, B, C                                      ____Cold sores                   ____Alcohol and/or Drug abuse

       ____Reaction to local anesthetic                  ____Diabetes                      ____Fainting Tendency

       ____ Kidney disease                                        ____ currently being treated for mental health issues

____Heart Disease (ie. pacemaker, angina, rheumatic fever)______________________________________________________

____History of MELANOMA? (date, location on body & details):___________________________________________________

Do you have a FAMILY history of MELANOMA? Yes/No; if YES, which relative?_________________________________________

____CANCER (what type?): _________________________________________________________________________________

Are you PREGNANT or BREASTFEEDING?__________________________________________________________________

Do you plan to become pregnant within the next two years?__________________________________________________

Are you taking hormones or birth control? _________________________________________________________________

List any CURRENT or PAST illnesses not mentioned___________________________________________________________________________________________________________________________________________

List any SURGERIES: ___________________________________________________________________________________

 Do you have any chronic/major health condition?  ___________________________________________________

PRIMARY reason for Referral: ____________________________________________________________________

 ____I understand that this scheduled appointment is only for me, and that no other family/friends will be seen without an appointment/referral

____ I understand that after a ONE YEAR period without seeing Dr. Storwick and/or Dr.Ting, I will require a new referral.

____I also understand that I will be discharged back to my referring physician once my assessment/treatment is complete, unless otherwise requested by Dr.Storwick +/or Dr.Ting

____I understand that 24 HOURS NOTICE is required for CANCELLATIONS

Signature:  ____________________________________________Date: _________________________________