MyDovetale - Emergency Department Virtual Care Intake Form

Full Name (on Health Card)*

Date of Birth (dd/mm/yyyy)*

12 character Health Card Number*

Health Card Expiry date (dd/mm/yyyy)*

Home Phone Number*

Mobile Phone Number

Email Address*

Confirm Email Address*

Street address (Please put N/A if you currently do not have a fixed address)*

City*

Postal Code*

Other Language

Primary contact - Full Name

Primary contact - Relationship

Primary contact - Street address

Primary contact - City

Primary contact - Province

Primary contact - Postal Code

Name of Medical Primary Care Provider (Please put N/A if you currently do not have a Primary Care Provider)*

Primary Care Provider address*

Preferred Pharmacy Name

Preferred Pharmacy Address

Preferred Pharmacy Phone Number

Preferred Pharmacy Fax Number

Medication History

Allergy History