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Intake Form
To submit your intake form, simply complete the fields below.
Date of Birth
(Required)
MM slash DD slash YYYY
Sex
(Required)
Male
Female
Name
(Required)
First
Middle
Last
Parents Name
(if under 18 years old)
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Home Phone
(Required)
Cell Phone
Work Phone
Email
(Required)
Enter Email
Confirm Email
Health Card Number
(Required)
Do you have any known respiratory issues?
(Required)
Yes
No
If yes, please indicate:
(Required)
Are you immunocompromised?
(Required)
Yes
No
Is telecare of interest to you?
(Required)
Yes
No
If yes what type of device would you use (e.g tablet, mobile)
(Required)
Are you currently receiving any of the following services? Please check if applicable:
ACSD (Assistance for Children with Severe Disabilities))
ODSP (Ontario Disability Support Program)
WSIB (Workplace Safety and Insurance Board)
OW (Ontario Works)
Blue Cross (DVA)
Insurance Information
Insurance Company
Insurance Phone Number
Personal Insurance Number
Consent
I give consent to UHAC to mail my doctor my results.
Doctors Name
Clinic Name
Interested in our clinics newsletter? We'd love to keep you updated on our clinic and the newest tech!
I consent to receiving the promotional materials:
by email
by mail
both
How did you hear about us? We'd love to say, "Thank you!"
Doctor or Medical Professional
Hospital
Friend/Family/Other
Or chose one if applicable
Internet Search
Facebook
Lyric Advertisement
Yellow Pages
Signature
(Required)
Phone
This field is for validation purposes and should be left unchanged.
