Name: | DOB: | MRN: | PCP:

Emergency Department Virtual Care Intake Form

I can confirm that I am 18 years or older*
Have you previously received care at St. Joseph's Healthcare Hamilton?*
Legal Sex*
Province*
Language of preference/comfort for communication*
Primary contact home address is the same as the Patient's address above.
I currently have no primary care provider
By submitting this form I consent to electronically communicate with and receive virtual care at SJHH*.