New Patient Intake Form

Welcome to Perpetual Health Centre — where your health, comfort, and time matter to us. Please complete the following form as accurately as possible. This form is designed to work on all devices; however, we recommend using a computer for the optimal experience.

Type of Care Requested *

Personal Information

Emergency Contact

Health Coverage

BC Services Card (MSP)? *
Private Insurance? *

Family Physician

Do you have a family physician?
Can we share info with them? *

Medical History

Social History

Smoking *
Alcohol *
Recreational Drugs *

Reason for Visit

I'm also interested in learning more about

Patient Policy Agreement

Our goal is to provide high-quality, timely, and compassionate medical care to all our patients. To ensure a respectful and efficient environment, we kindly ask all patients to review and agree to the following policies:

Respectful Behaviour

  • Respect all clinic staff and patients.
  • No abusive, aggressive, or disrespectful behaviour will be tolerated.
  • Violations may result in discharge from the clinic.

Appointments & Missed Visits

  • 24 hours’ notice is required for cancellations or rescheduling.
  • Missed appointments without notice will incur a $50 fee.
  • Three missed appointments may result in discharge from the clinic.

Prescription Renewals

  • Request renewals at least 7 days in advance.
  • Routine renewals must be discussed during a visit.
  • Urgent refills may not be accommodated and may incur a fee.

Controlled Substances

  • This clinic does not prescribe benzodiazepines for routine or long-term use.
  • This policy is final and based on safe medical practice standards.

MSP and Private Billing

  • BC residents with MSP are not billed for covered services.
  • Some services may not be covered under MSP.
  • Out-of-province/country and private services will be billed directly.
  • Executive Health and non-MSP services are billed accordingly.

Communication Policy

  • Messages are responded to within 1–2 business days.
  • Urgent concerns should be directed to the clinic or emergency services.

Consent to Communicate Electronically

  • You consent to be contacted by email, text, or voicemail.
  • You understand electronic communication has risks and may not be secure.
  • You may revoke consent at any time in writing.