Help with entering the Patient intake Form
We have made every possible effort to have the Patient Intake Form work smoothly. However, we acknowledge that each browser and operating systems have their own peculiarities; for instance, sometimes the dropdown arrows do not appear in the boxes. Should this happen, click in the box to trigger the dropdown. If you find that the fillable pdf is not working on your platform, please print the form and fill it in by hand. The finished form can then be scanned or photographed and returned to us by email.
Please refer to your OHIP card when filling out the form.
First Name: As it appears on your OHIP card
Middle Initial: The first letter of your middle name as it appears on your OHIP card.
Last Name: As per your OHIP card
Name you use: The name you are commonly referred to as
Gender: Currently, the Assistive Devices Program (ADP) requires either M or F.
Title: How you wish to be addressed
Birth Date: Please refer to your OHIP card to ensure your birthdate is correctly recorded.
Phone Numbers: Your contact phone numbers.
Email: Your primary contact email
Contact me by: Indicate which contact method you prefer.
Street #: The house or dwelling number.
Street Name: The name of the street. Street Type: From the dropdown
Dir: Street direction from the dropdown
Suite/Unit: Usually an apartment #
RR# and Conc: For rural addresses
Other Address: Usually for out of province addresses.
City: Please select from the dropdown.
Prov/State: Is preset to Ontario; if you are from out of province, please select from the dropdown.
Other: Used for regions other than a Canadian Province or American State.
Country: Preset to Canada.
P/C (Canada): Enter your Postal Code
Zip (US): For American clients
Family Doctor: Please indicate if your Family Health Care Professional is a Family Doctor or a Nurse Practitioner.
First Name: First name of your Health Care Professional.
Last Name: The last name.
How did you hear?: Kindly tick the circle that best pertains to you.
Insurance: Please indicate if you require documentation.
The second page of the Patient Intake Form only needs to be filled out if the patient is legally unable to make health decisions for themselves. If you are the care-giver for an adult patient (i.e. are making appointments for the patient), we assume that you are the designated representative in the Patient's Power of Attorney for Personal Care. For more information on Power of Attorneys, please see the Ontario Office of the Public Guardian and Trustee.
Type of Representative: Please select one. These are the only relationships currently accepted by the Assistive Devices Program (ADP).
Documentation: If you indicate Yes, all documentation will be addressed to you.
Communication: If Yes, we will communicate with you directly instead of the patient.
Please enter your name and Title for contact purposes, and your contact information.
Please indicate the best way to reach you.
Kindly provide your address if different than the patient's.
Please fill out this box if the patient's legal representative is a company.