Emergency Department Virtual Care Intake Form

I can confirm that I am 18 years or older*

Yes

Have you previously received care at St. Joseph's Healthcare Hamilton?*

YesNo

Full Name (on Health Card)*

Date of Birth (dd/mm/yyyy)*

Legal Sex*

MaleFemale

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*

Province*

Ontario

Postal Code*

Language of preference/comfort for communication*

English

French

Other

Other Language

Primary contact - Full Name

Primary contact - Relationship

Primary contact home address is the same as the Patient's address above.

YesNo

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*

I currently have no primary care provider

YesNo

Preferred Pharmacy Name

Preferred Pharmacy Address

Preferred Pharmacy Phone Number

Preferred Pharmacy Fax Number

Medication History

Allergy History

By submitting this form I consent to electronically communicate with and receive virtual care at SJHH*.

Agree