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New Patient Form
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NEW PATIENT FORM for DR MUKHTAR

FIRST NAME

MIDDLE NAME

LAST NAME

Birth Date:

Email:

Health Card Number:

VC:

Expiry:

Home Telephone:

Cell Phone:

Address:

City:

Postal Code:

PAST/CURRENT DOCTORS

MEDICATION:

PLEASE CHECKMARK YES OR NO TO THE QUESTIONS BELOW:

EPILEPSY (SEIZURES)

Yes No

ANEMIA

Yes No

ARTHRITIS

Yes No

STROKE

Yes No

CANCER

Yes No

BLEEDING DISORDER

Yes No

FIBROMYALGIA

Yes No

ECZEMA

Yes No

MIGRANE HEADACHES

Yes No

ALLERGY CONDITION

Yes No

OSTEOPOROSIS

Yes No

ASTHMA

Yes No

DIABETES

Yes No

GLAUCOMA

Yes No

HIGH BLOOD PRESSURE

Yes No

PSYCHIATRIC ILLNESS

Yes No

HIGH CHOLESTEROL

Yes No

ANXIETY

Yes No

HEART DISEASE

Yes No

INSOMNIA

Yes No

Tobacco Use Per Week:

Narcotic Used In Past 2 Years:

Allergies:

Alcohol Used Per Week:

Exercise (How Much):

Surgeries:

I agree that all the information in this application to be a patient at Grand Marais Medical Centre is correct and if found at anytime there has been any dishonesty/false information it may lead to termination of my relationship with Grand Marais Medical Centre

DATE:

SIGNATURE:

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Contact Info:

Phone: (519) 977-4029
Email: doctormukhtar786 @gmail.com
Address: 2930 Dominion Boulevard, Windsor, ON N9E 2MB

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New Patient Form
Services
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New Patient Form
Services
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