Register Now!
Expected date of delivery:
 
Obstetrician's/Midwife's Name:  
Family Physician's Name:  
Baby's Physician's Name:  
Personal Info
Last Name (on health card):  
All Given Names:  
Initial:
Maiden Name:  
Date of Birth: /  /   
Marital Status:  
Address:  
Apt. No.:
City / Town:  
Province:  
Postal Code:    
Home Phone No.:    
Work Phone No.:   Ext: 
Email:    
 Patient Medication History:
Taking any Medications:

 
 My Medications:
I will bring my medications with me
My Drugstore/Pharmacy is  
INSTRUCTIONS
Please list below any medications that you are now taking. Include PRESCRIPTION, non-prescription medications and vitamins or supplements. Other examples include: patches, inhalers, drops and medicated creams.
Medication Name Why do You take
this medication?

(i.e. heart/diabetes/blood pressure)
What dosage of
medication do you take
and how do you take the medication?

(i.e. By mouth, injection, drops)
How often do you
take this medication?
 My Allergies:
Do You have Allergies
Allergic to: Type of reaction:
(e.g. rash, shortness of breath)
Medication prescribed
to treat reaction:
 Health Insurance:
Province:  
Health Card Number:  
Version Code:
 
Expiry Month:  Expiry Year: 
Substitute Decider
Name:  
Relationship:  
Address:  
City/Town:  
Province:  
Home Phone No.:  
Work Phone No.:
Additional Insurance For Semi-Private or Private Accomodation Requests
Name of Insurance Co.:
Policy/Certificate No.:
Class No.:
Subscriber's Last Name:
Subscriber's First Name:
Relationship to Subscriber:
Employer Name:
  




3045 Baseline Road Ottawa, Ontario, Canada K2H 8P4 | Contact Us