Dr. Pat Nesbitt M.D. ............Family Medicine and more ............drpat@ live . ca NOW BOOKING PATIENTS AT CAULFEILD 604 922 1544

Follow-up form, or One-Time / Walk-In Form

* Indicates required field

Name ( As it appears on your medical card ) *

First

Last

Date of Birth: such as " 17 March 1983" *

Personal Health Number ( You can omit this if you have been seen before. If you don't know it, call your pharmacy, and they can give it to you.) *

Email *

Phone Number *

Who is your regular family doctor? (If you have one.) We may want to send them a report. *

What is the main reason you need to talk to a doctor today? ( Please be as specific as you can)t *

What other medical problems do you have? ( Operations, hospitalizations, things you get treatment for .....) *

What medications are you on? ( Please include ASA, vitamins, supplements, etc. ) *

Do you have any medical allergies? *

If you have an allergy, to what? And what happens to you? *

If you are needing a prescription, which drug store do you go to, and what location? ( We can fax the Rx directly. We probably already have the fax number. ) *

Which kind of appointment would you prefer? *

Phone appointment Zoom appointment ( You need an email.) In person appointment ( You will need a mask )

When would be the best time for your appointment? *

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