Avail Walk-in Clinic

Patients Name:

Date of Birth:

Age:

Health Card Number:

Version Code

Expiry Date:

Address

City Province Postal Code

Phone Number:

Family Doctor:

Drug/ Food Allergies:

Medical History:

Surgical History:

Reason for visit:

BP:

HR:

SPO2:

Are you interested in the benefits of "Medical Cannabis Treatment"?

Email:

Tel:

If Yes, Please include the above contact information and a Patient Care Coordinator will reach out to you shortly.