AB___________

JM_____________
PATIENT INFORMATION (FEMALE)

LAST NAME: _______________________________ FIRST NAME: ________________________ AGE:

________________
(Write your name exactly as it appears on your health card)

HEALTH CARD NUMBER: ________________________________ DATE OF BIRTH:

_______________________________
​(Include the version code – the two letters after the number) ​(Please write out the month)

MAILING ADDRESS: ________________________________________CITY: ______________ POSTAL

CODE: ___________

EMAIL ADDRESS: ______________________________________ I CONSENT TO EMAIL

COMMUNICATION ____________
HEIGHT:(feet) ______________________ (Yes or No)
Weight: (Lbs.) __________________
Email communications may contain confidential information, because email is not
secure, please be aware of associated risks of email transmission
PHONE (CELL): _____________________ (HOME):
_____________________

FAMILY DOCTOR: _________________________ PHONE:

_______________________ FAX:
_______________________

PHARMACY:
______________________________________________
FAX: __________________________________

PHONE:
_________________________________
REFERRING DOCTOR:
_____________________________________ FAX:
____________________________________

PHONE:
__________________________________

PARTNER INFORMATION Male/Female

LAST NAME: _______________________________ FIRST NAME:
________________________ AGE: ________________
(Write your name exactly as it appears on your health card)

HEALTH CARD NUMBER: ________________________________

DATE OF BIRTH: _______________________________
(​ Include the version code – the two letters after the number) (​ Please write out the month)

PREVIOUS SPERM ASSESSMENT: DATE:

_____________________
LOCATION:_________________________________
MAILING ADDRESS:
______________________________________CITY: ______________
POSTAL CODE: _____________
EMAIL ADDRESS: ______________________________________ I
CONSENT TO EMAIL COMMUNICATION ___________
​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ (Yes or No)
Email communications may contain confidential information, because email is not secure, please be aware of associated risks of email transmission

(FEMALE) HEIGHT:(feet) ______________________ (FEMALE)

Weight: (Lbs.) __________________
PHONE (CELL): _____________________ (HOME):
_____________________
FAMILY DOCTOR: _________________________ PHONE:
_______________________ FAX: _______________________