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New Patient WAITLIST Intake Form
Failure to complete intake forms in full will results in further delays in your form being processed
Please note:
Completion and submission of our intake form does
NOT
guarantee that you will be accepted as a patient at Marine Gateway Medical Clinic. This is a WAITLIST for future doctors joining our practice
Patients who are accepted are placed on a waiting list and are only contacted for an appointment when physician availability permits
IF YOU HAVE A MEDICAL EMERGENCY
PLEASE VISIT YOUR LOCAL EMERGENCY DEPARTMENT.
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* Indicates required question
Full Name on Care Card/BC Services Card (Legal)
*
Your answer
Preferred Name (Alias)
Your answer
Care Card/BC Services Card/MSP Number (
Do not add spaces between the numbers. Should start with a 9
)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Female
Male
Other:
Marital Status
*
Single
Partnered
Married
Separated
Divorced
Widowed
Home Address
Street Number and Name, City AND Postal Code
-- ex. 1234 Bird St, Richmond, BC, V7S 1Y8
Your answer
Street Number and Name
ex. 1234 Bird Street
*
Your answer
City
ex. Richmond
*
Your answer
Postal Code
ex. V7S 1Y8
*
Your answer
Cell Phone Number
*
Your answer
Home Phone Number
Your answer
Work Phone Number
Your answer
Email Address
Your answer
Do you consent to electronic communications through the portal (secure emailing system) and/or email if needed?
*
Yes
No
Emergency Contact (
Name, Phone Number, AND Relationship to you
-- ex. Jane Daniel, 604-123-4567, Mother)
Your answer
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