Allergy

1

Patient Full NameFormat: Last name, First name

2

Health Card NumberLeave blank if you do not have one (i.e Out of country, refugee etc.)

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.

4

Date of Birth* This field is required.Enter in this format: YYYY-MM-DD. For example: 2020-12-31

5

Email

example@example.com

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

7

Referring Doctor (leave blank if not applicable)

8

Family Doctor (leave blank if not applicable)

10

Allergic Symptoms Ears (please select all that apply, if you're unsure do not check the box)

Pruritus

Infection

11

Allergic Symptoms Nose (please select all that apply, if you're unsure do not check the box)

Sneezing

Rhinorrhea

Obstruction

Pruritus

Mouth Breathing

13

Type a question

Type option 1

Type option 2

Type option 3

Type option 4