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New Patient Questionnaire
New Patient in-take form
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* Indicates required question
Email
*
Your answer
First Name
*
Your answer
Last Name
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Are you interested in registering with a family physician at Drewry Medical Clinic?
*
Yes
No
Are you currently enrolled with a family physician at another office?
*
Yes
No
Which of the following applies to you? *
*
My family physician has moved to another community
I have moved to another community
My physician is no longer available due to illness/death/retirement
My physician is no longer available due to change of practice type
Up until now I have not had or felt the need for a family physician
None of the above
You are enrolling on behalf of:
*
Yourself
A child/children
A family
A dependent adult(s)
Are you interested in a female or male physician?
*
Female
Male
Any
How did you hear about our clinic?
*
Online
Health care connect
Other
Additional Comments
Your answer
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