Patient Intake Form

Help our medical and pharmacy teams understand your needs before your visit. Your information is used to support safe, coordinated care.











1. Patient Details

Fields marked * are required.

Complete the required fields above to continue.

Step 1 of 11

2. Contact & Address

Phone Numbers

Step 2 of 11

3. Contacts & Previous Provider

Emergency Contact

Guardian (if under 18)

Previous Provider

Step 3 of 11

4. Medical History

Select every condition you have had. This expanded list helps the care team prepare for your visit.
































Step 4 of 11

5. Lifestyle

Smoking



Alcohol

Step 5 of 11

6. Tests & Exams

Enter the most recent year, if known.

Step 6 of 11

7. Immunizations

Enter the most recent year, if known.

Step 7 of 11

8. Family History








Step 8 of 11

9. Current Medications

This helps the care team reconcile medications and avoid interactions.

Step 9 of 11

10. Pharmacy Preference & Integrated Care

New Era Pharmacy is conveniently located on-site. Choosing it can make prescription coordination easier, but your choice of pharmacy is always yours.



Your Pharmacy Details

Pharmacy to Transfer From

New Era Pharmacy Services I’m Interested In








Prescription Transfer Authorization

Use your finger or mouse to sign.

The patient name is automatically filled from Step 1. The authorization date is added automatically in Vancouver time when the form is submitted. No pharmacy choice or consent will be preselected.

Step 10 of 11

Review & Submit

Patients will review their answers before securely submitting the completed intake form.

Prototype only: secure submission, PDF generation and confirmation messaging will be connected after this flow is approved.
Step 11 of 11Submit Disabled