Family Physician

If you were referred by the hospital or walk in clinic please enter both doctor referring doctor and your family physician

Name of your doctor's Medical Clinic

Clinic that your attend for medical care

Date of Birth- dd-mm-yr

Do you live in a community subsidized home ?

Please name the organization

Name of case worker or caregiver

Please enter the name last name and how is this person related to you.

Caser worker phone number?

Next of Kin

Individuals that you will want us to call in case of needing urgency(ie: dizziness, fainting)

Reason for referral(write in detail)

Lesion location or affected area ? How is this lesion affecting you ? Is the lesion changing? Describe How long have you had this lesion? Please describe in detail how this lesion looks to you ? What is the size of the lesion ? Why do you want to get it removed?

List of your current medications and dosages

Allergies (medications, food, animals, environment)

Vitamins, supplements herbal remedies

Personal Medical history

A personal medical history may include information about past hospitalizations, immunizations, and abnormal results of physical exams, x-rays ultrasounds, other tests, and screenings.

Personal Surgical history

A personal surgical history may include information about past surgeries and reasons.

Infectious Disease Medical History

A record of health information about infections such as Hepatitis A, Hepatitis B, Hepatitis C, HIV

Occupation

Do you take any blood thinners?

Warfarin, ASA, Plavix, Apixaban

Do you have family history of Melanoma

Cancer of the skin

Do you consume alcohol? If yes, please describe how many drinks per week, approximately.

Do you use recreational drugs?

Please describe type of recreational drugs consumed and frequency of use, as well as any adverse effects.

Location

1923 17 Avenue SW, 2nd floor
Calgary, AB T2T0G1

Hours

Monday — Friday
8:00 am — 5:00 pm

Saturday — Sunday
Closed

Contact

phone: (403) 686-3628