Your first visit

 
iHealthMD is experiencing unprecedented demand for Family Physician services in North Vancouver. Several other practices have either closed or reduced their services due to the COVID-19 pandemic. This has created a surge of applicants and space is limited.
 
If you are interested in becoming a New Patient of iHealthMD then please fill out the brand new web-based application form. Your information will be forwarded to us directly.
 
SUBMITTING AN INTAKE FORM DOES NOT GUARANTEE WE WILL BE ABLE TO FIND YOU A FAMILY PHYSICIAN.
 
We ask that you do not call our office or send emails enquiring about the status of your application. You will be contacted in due time by email or phone when your application comes up for review.
 
In the meantime, for any urgent health concerns or for prescription refills please use our Walk-In Service.
 
New patient intake form

 

    YesNo



    First available doctorDr GoldsteinDr.MotaDr.Oveisi

    Personal Information








    Address*




    Do you have a BC Personal Health Number* YesNo

    Current Gender Identity?

    MaleFemaleTransgender Male/FTMTransgender Female/MTFAdditional CategoryDecline to answer

    What sex were you assigned at birth?

    MaleFemaleOtherDecline to answer

    Emergency Contact





    Social History







    Medical History

    (including diabetes, airways disease, heart failure, hypertension, neurological conditions, mental health)

    Surgical History

    (including colonoscopy & gastroscopy)

    Everyday Living

    YesNo
    YesNo
    YesNo

    Family Medical History (in 1st degree relatives)

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


    Prescription Medications

    Non-Prescription Medications


    Medication Allergies


    Risk Factors

    YesNo

    days

    Healthy & balancedNeeds improvement

    YesNo

    days


    Preventative Medicine

    YesNo

    (please list the date you last had the following, if not applicable write n/a) YesNo

    Tests

    DateN/A

    DateN/A

    DateN/A

    DateN/A

    DateN/A

    DateN/A

    Vaccinations

    DateN/A

    DateN/A

    DateN/A

    DateN/A

    DateN/A