Wellness Centre Patient/Client Intake Form (Canada)

Form Template

The Wellness Centre Patient/Client Intake Form (Canada) is a template which can be used by Wellness Centres upon intake of a patient for treatment.

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The form contains entries for the name, address, phone numbers etc of the patient, as well as a list of questions about the patient's medical history, including heart problems, diabetes, blood pressure complications, skin cancer etc. The form also checks if the patient currently has any implants/pacemakers, wears contact lenses, is a smoker, currently pregnant etc.

The form goes more in depth with particular skin conditions and treatments being used for them (laser surgery, microdermabrasion, rash, hives, using Retin-A, Accutane, Acne creams etc). There is also a section that allows the patient to further detail their concerns over their current skin care regime, as well as list any adverse reactions they have had to skin products. Finally there is an informed consent and release ending with a signature section.

  • Signature Capture
  • Conditional Fields
  • Submission Editing
  • Reference Data
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