Intake Form — OttawaNPservices Clinic

First Name*

Middle Name

Last Name*

Date of Birth*

OHIP / RAMQ

Address*

City*

Province*

Postal Code*

Email*

Phone Number*

Preferred Pharmacy

Family Physician

family physician’s name

Type of appointment*

Type of heatlh service

Duration of an appointment

Day of week

Message*

Consent*

I hereby acknowledge that the services rendered to me are private and subject to a fee-for-service arrangement.
I have been duly informed of my right to withdraw from these services at any given time.
Upon submission of the requisite form, I agree to make payment for the services received.