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Consent

Part (1) This section must be completed for all patients:

Patient Name

Preferred Name

Sex

M F X

If patient is 19 years or younger:
Parent/ Guarantor Name

Health Card Number / Expiry Date

Full Address

City / Postal Code

Telephone

Email

(I Consent To Electronic Communications)

PLEASE SIGN BELOW TO ASSUME RESPONSIBILITY FOR ALL FEES ASSOCIATED WITH THE TREATMENT PROVIDED AND I UNDERSTAND THAT FEES MAY NOT BE COVERED BY INSURANCE BENEFITS
FAILURE TO PAY WITHIN 3 MONTHS WILL RESULT IN AUTOMATIC REFERRAL TO COLLECTION AGENCY.

Signature of Patient, Parent or Guardian

Click to Sign

Date:-------------

Privacy Statement

PART (2) This section must be signed for all patients:

Signature of Patient, Parent or Guardian

Click to Sign

Date:-------------

1. ACKNOWLEDGEMENT OF PRIVACY STATEMENT
Having read and understood the Privacy Statement for Patients, I hereby consent to the collection, use and disclosure of my personal information as presented in the Statement.
Please list here ONLY if you have restrictions:
o RESTRICTED ACCESS- My personal information shall NOT be provided to the following:

o RESTRICTED INFORMATION- Personal information disclosed shall NOT include my following personal information;

2. AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION
I give permission to health care institutions to release my personal health information gathered prior to, as well as after the date of signature below. I may withdraw my permission at any time, in writing, as long as the information has not already been released. I may also indicate an expiry date for this authorization.

If you are requesting an expiry, please indicate a specific Authorization Expiry Date:

Allergies

Medications

51. Do you take any medications?

Yes No

If yes, list all medications below including all prescriptions, insulin, herbals, and over the counter medication.

Medication List

Pharmacy name

location / Phone #

If you have significant changes to your health before your surgery, please contact your surgeon’s office.

truForm by PBHS

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Consent

Consent

Click to Sign

Privacy Statement

Click to Sign

Patient Health History Questionnaire

Patient Health History Questionnaire

DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Allergies

Allergies

Medications

Medications

Medication List

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Main Header

Consent

Consent

Click to Sign

Privacy Statement

Click to Sign

Patient Health History Questionnaire

Patient Health History Questionnaire

DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Allergies

Allergies

Medications

Medications

Medication List

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.