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mediCare
📝 New Patient Intake Form
Let's get you set up! This will only take a moment.
👤 Personal Information
Full Name
Email Address
Phone Number
Gender
Select Gender
Male
Female
Other
Prefer not to say
Date of Birth
Nationality
🩺 Health & Lifestyle Information (Optional)
Existing Medical Conditions
Allergies
Medications Currently Taken
Smoking Status
Select Status
Non-smoker
Current Smoker
Former Smoker
Alcohol Consumption
Recent Surgeries/Treatments
🏥 Consultation Preferences
Preferred Consultation Type
Select Type
Video
Audio
Chat
In-person
Preferred Doctor Gender (Optional)
No Preference
Male
Female
Other
Preferred Language(s)
Best Time for Consultation
Select Time
Morning
Afternoon
Evening
🆘 Emergency Contact Details
Contact Person's Name
Relationship to Client
Contact Person's Phone
Contact Person's Email (Optional)
🔒 Account Security
Password
Confirm Password
✨ Optional Information
Insurance Provider
Insurance ID / Policy Number
Referred By
Submit
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