Consent for Information Gathering
This information is collected to assist in providing medical care, and is collected and retained in accordance with the Yukon's Health Information Privacy and Management Act (HIPMA).
The answers to the questions will not influence whether or not you are accepted into your matched doctor's practice. If you prefer to complete the questionnaire after your match is confirmed you are welcome to do so, but we like to have a snapshot of your health history before we first meet.
You are also welcome to arrive early for your first appointment and request a paper copy of the form.
Completing this intake form and the Equinox Patient Agreement Form does not guarantee your match will be accepted; after the initial intake visit both doctor and patient must agree to the match, and the doctor may reject the match if there is a relationship conflict that would preclude optimum patient care (for example an existing personal relationship outside of the clinic).
By completing this form you agree you have read and understand the information above. Thank you!
Previous and Current Health Care Providers
Past Medical History
Surgeries
Hospitalizations
Medications
Health Risks and Habits
Thank you for taking the time to complete this form