Due to COVID:19, all consultations will be done virtually either by phone or telemedicine for all new and existing clients

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Intake Form - Mens

New Patient Information
Medical History
Men's Questionnaire
Family Medical History
Substance & Dietary Habits

First Name:
Last Name:
Email:
Phone:
Address:: Line 1:
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Country:
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Date of Birth (DD-MM-YYYY):
Age:
Marital Status:: SingleMarriedDivorcedWidowedSeparated
Number of Children:
Is there any chance you're pregnant?:: YesNo
Ontario Health Card Number:
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Additional Phone Numbers:: Home/Work/Cell
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Phone: 705-760-1239

Address: 291 Charlotte St., Peterborough, Ontario, Canada, K9J 2V6

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