New Patient Form in Vancouver, Whistler, Fort St. John, BC

"*" indicates required fields

First Name*

Middle Name*

Last Name*

Age*

Date of Birth*

please follow this format (MM/DD/YYYY)

Sex*

Male

Female

Prefer not to say

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Numbers*

Type

Number

Email*

Occupation*

Care Card #*

Private Insurance*

Height*

Weight*

Shoe Size*

Family Doctor*

Spouse / Parent /Gaurdian*

Contact Number*

Please state the nature of today's visit.*

Whom may we thank for referring you to the office?*

Health

Do you have prolonged bleeding after a cut?*

Yes

Do you smoke?*

Yes

Quantity*

For how long?*

Do you drink alcohol?*

Yes

How often do you drink?*

Do you have diabetes?*

Yes

When were you diagnosed with diabetes?*

Does anyone in your family have diabetes?*

Yes

Who has diabetes?*

Please list your current medications and dosage*

Are you allergic to any food or medications?*

If you have been tested for HIV, please provide your result*

Negative

Positive

Have you ever had Hepatitis? If so, what type?*

Have you had any serious illnesses or operations within the past 5 years?*

Please list any previous foot injuries or foot surgeries*

Do you have, or have ever had...*

Heart Trouble

Faint Easily

Eye Problems

Liver Problems

High Blood Pressure

Stomach Problems

Rheumatic Fever

Kidney Problems

Arthritis

Epilepsy

Asthma

None of the above

If you have been tested for HIV please provide your result

Accepted file types: jpg, pdf, Max. file size: 25 MB.

I prefer that the office contact me the following way to send reminders*

Home Phone

Cell Phone

Acknowledgement

Please read and acknowledge the following by signing below

My health insurance coverage under the BC Medical Services Plan is current. If for any reason my MSP coverage is not up to date, then I accept responsibility for payment for services rendered which are an MSP benefit. I understand that MSP does not cover all podiatry services. I understand that payment methods for services are: Cash, Interac/Direct Debit, Visa or Mastercard, and are due at the time services are rendered.
ASSIGNMENT OF MEDICAL SERVICES PLAN BENEFITS TO OPTED OUT PRACTITIONER I authorize the Medical Services Plan to pay Dr. Boroditsky directly for all reimbursements for benefits payable to me under the Medical and Health Care Services Regulation for care provided to me. I make this assignment in full knowledge of the amount that I will personally responsible for and the amount that is reimbursable by the Medical Services Plan, which will be directed to Dr. Boroditsky to be applied against any outstanding monies I owe for services provided.
This form allows the below-named practitioner to receive MSP reimbursements directly for services that are MSP benefits. Your practitioner, by law, must advise you of his full fee and what portion will be reimbursable by MSP.
Practitioner: Dr. Boroditsky MSP Practitioner & Payment#: 60082
I understand that once I make an appointment, both time & space has been reserved for me. If I fail to give a minimum 48 hours notice to cancel or reschedule an appointment or if I don’t show-up for a reserved appointment time, I understand that I will be charged a cancellation or no-show fee of $75. This policy allows for mutual consideration for both your time and mine.Aside from a written reminder slip, I understand that the office will make an attempt to remind me of my appointment time.

Consent*

I hereby give my permission for Dr. Boroditsky, or his staff designate, to, if needed, send my medical information to me via email. I understand that email is not secure, but I agree to this consent until further notice:

Consent for Virtual Care

Our clinic uses virtual care technology to communicate with patients, including video visits and audio calls. The information exchanged with these tools may be confidential and personal in nature. We are very careful on our end to keep the information confidential. Just like online shopping or email, virtual care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed with providing virtual care.

In order to improve privacy and confidentiality, you should also take steps prior to participating in a virtual care encounter to ensure you are within a private setting. You should not use an employer's or someone else's computer/device as they may be able to access your information. If it is determined that you require a physical exam, you may still need to be assessed in person.

You should also understand that virtual care is not a substitute for attending the emergency department if urgent care is needed. If you would like more information, please discuss with our reception. The main advantage of virtual care is convenience. Also, by staying home, you remain protected from contagious illnesses like COVID-19.

I agree to participate in virtual care despite the inherent privacy risk:

Name of Patient*

Signature*

Date*

MM slash DD slash YYYY