Your first visit

 
iHealthMD would like to apologize for the delay in processing new patient applications for Dr Brennan and Dr Goldstein. There has been overwhelming demand for our new doctors!
 
For existing applicants who have already completed the old intake form, please be assured that your application has been received and will be processed.
 
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 and scheduled for a meet & greet appointment.
 
Interested in becoming a New Patient of iHealthMD? Please, fill out the brand new web-based application form. Your information will be forwarded to us directly so that we can schedule your appointment. 
 
In the meantime, for any urgent health concerns or for prescription refills please use our Walk-In Service.
 
New patient intake form

 

    YesNo



    Dr.GoldsteinDr.BrennanDr OveisiFirst available doctor


    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