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Allergy Clinic
Hi there, please fill out and submit this form before your appointment with the specialist.
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1
Patient Full Name
Format: Last name, First name
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2
Health Card Number
Leave blank if you do not have one (i.e Out of country, refugee etc.)
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3
Cellphone Number
*
This field is required.
Enter phone number WITHOUT any dashes or '1" in front of it. For example: 9058979228. Enter the SAME PHONE NUMBER that you have been receiving text messages from the clinic.
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4
Date of Birth
*
This field is required.
Enter in this format: YYYY-MM-DD. For example: 2020-12-31
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5
Email
example@example.com
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6
Current Address Including postal code
*
This field is required.
Enter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6
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7
Referring Doctor (leave blank if not applicable)
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8
Family Doctor (leave blank if not applicable)
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9
Allergic Symptoms Eyes (please select all that apply, if you're unsure do not check the box)
Pruritus
Burning
Lacrimation
Swelling
Infection
Discharge
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10
Allergic Symptoms Ears (please select all that apply, if you're unsure do not check the box)
Pruritus
Infection
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11
Allergic Symptoms Nose (please select all that apply, if you're unsure do not check the box)
Sneezing
Rhinorrhea
Obstruction
Pruritus
Mouth Breathing
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12
Allergic Symptoms Throat
Soreness
Post0nasal discharge
Palatal
Mouth Breathing
Purulent Discharge
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13
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
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