Patient Intake Form

Patient Information

First Name *

Last Name *

Date of Birth *

Age

Gender *

Phone Number *

Email

Patient/Employee ID

Employer/Company Name

Occupation/Job Title

Reason for Visit *

Pre-employment exam Work injury Return-to-work eval Annual screening Drug/alcohol test Other

Upload ID Document *

No file selected yet.

Surgical History

Procedure & Date

Family History & Current Medication

Family History (Check if any apply)

Heart Disease Diabetes Cancer Hypertension Stroke Mental Illness Genetic Disorders

Current Medications (incl. OTC & supplements)

Working at Heights Assessment

This section is only needed if you work at heights or in confined spaces. Skip it if it does not apply to you.

Working at Heights Assessment

General and Substance Use

Drug or alcohol dependency

Yes No

Past or current rehabilitation/counseling

Yes No

Overall Assessment

Any reason you feel unfit to work at heights or in confined spaces?

Yes No

Reason:

Final Confirmation

Schedule Your Appointment

Would you like to schedule an appointment now, or just complete your registration?

Yes, schedule an appointment No, just complete registration

Please select your preferred appointment date and time. We'll confirm your booking and send you a reminder.

Preferred Date *

Preferred Time *

Additional Notes (Optional)

Review Your Information

Please review all the information you've provided before submitting.

What happens next?

• Your information will be securely stored
• Our team will review your medical history
• Your appointment is now scheduled and confirmed
• You'll receive confirmation via email/SMS
• We'll send a reminder before your appointment

Important Notes:

• Please bring your ID document to your appointment
• Arrive 15 minutes before your scheduled time
• Fasting may be required for certain tests
• Contact us if you need to reschedule

By clicking "Submit Registration" below, you confirm that all information provided is accurate and complete.

Patient Information

Medical History

Surgical History

Family History & Current Medication

Working at Heights Assessment

Working at Heights Assessment

Medical Conditions

Psychological Wellbeing

General and Substance Use

Overall Assessment

Final Confirmation

Schedule Your Appointment

Review Your Information

What happens next?

Important Notes: