Microsoft word - fiche_identification_clientele_medecin_famille_ang.docx

Identification Form for clientele
looking for a family doctor
Family Name: _____________________ First Name: _______________________________ Town: ________________________________________ Postal Code: _________________ Telephone (Home): _____________________________ Day  Evening  Weekend  Telephone (Cell): _______________________________ Day  Evening  Weekend  Telephone (Other): ______________________________ Day  Evening  Weekend  Sex: Female  Male  Date of Birth: ___________/________/_______ Health Insurance Card: ____________/___________/__________ Expiration: _______ /______ Language of communication: _________________________ CLINICAL INFORMATION
Do you have a family doctor?  Yes  No If Yes, what is his / her name and place of practice? ____________________________________ _____________________________________________________________________________ If No, have you previously had a family doctor:  Yes  No of last visit: ______________________________________________________ Reason for loss of your family doctor: ________________________________________________ If Yes, expected date of birth: ______________________________________________________ Have you been to the hospital in the last two years:  Yes  No If Yes, please check box and explain why:  Hospitalization: ____________________________________________________________  Emergency Room: _________________________________________________________  For an operation: __________________________________________________________ Are you currently being monitored by specialist doctors, or have you been in recent years? If Yes, by whom? (names and specialties): ___________________________________________ Are you currently receiving services from a CLSC?  Yes  No  Youth Clinic  Day Hospital  Psychosocial Reception  _______________________________________________________________________ Do you have one or more of the diseases listed below?
Yes (specify)
without hyperactivity (ADHD) Hearing impairment requiring an Drug or alcohol addiction or withdrawal during the past five Degenerative disease of the central nervous system, Alzheimer’s, Parkinson’s, multiple sclerosis Crohn’s disease, ulcerative colitis, lupus, rheumatoid arthritis and/or psoriatic arthritis Chronic renal failure Atrial fibrillation or other problem requiring the taking of Coumadin for Please send us your list of medications provided by your pharmacist and this
duly completed form by mail or fax to:
Guichet d’accès pour la clientèle orpheline Fax: 450 566-3323
I authorize the Argenteuil Health and Social Services Centre (CSSS d’Argenteuil) to transmit the
information necessary for the provision of care and services required by my state of health to the
physician who is willing to become my family doctor through this registration process.

I accept, if my state of health permits, to be followed by a specialized nurse practitioner.
Signature: __________________________________________________ Date: _____________________



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