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About
Consulting Anesthesia Services
FAQ
Contact

Patient Intake Form

Patient Intake Form

Please complete the questionnaire below. Only fill in what applies to your situation — fields left blank are treated as not applicable.

QUESTIONNAIRE FOR PATIENTS

COMPLETE ONLY WHAT IS APPLICABLE TO YOUR SITUATION

IDENTITY / PURPOSE (Mother)

Full Name:

Date of Birth:

Address in Canada:

Address in Home Country:

Phone Number:

Email Address:

STATUS IN CANADA (Mother)

Are you a Canadian citizen?

Yes No

If not, what is your citizenship?

Do you have a work permit?

Yes No

Work Permit #:

Do you have a study permit?

Yes No

Study Permit #:

Visitor Visa or other Status?

Yes No

Visitor Visa #:

Effective Date:

Expiry Date:

Have you applied for Permanent Residency Status?

Yes No

PR Effective Date:

PR Expiry Date:

UCI (Unique Client Identifier):

STATUS IN CANADA (Father)

Baby's Father's Name:

Baby's Father's DOB:

Is baby's father a Canadian citizen?

Yes No

If not, what is his citizenship?

Does father have a work permit?

Yes No

Work Permit #:

Does father have a study permit?

Yes No

Study Permit #:

Visitor Visa or other Status?

Yes No

Visitor Visa #:

Effective Date:

Expiry Date:

Has baby's father applied for Permanent Residency Status?

Yes No

PR Effective Date:

PR Expiry Date:

UCI (Unique Client Identifier):

Are you a Refugee in Canada?

Yes No

Refugee Number and Federal Health Number:

RESIDENCY IN ALBERTA (Mother)

When did you arrive in Canada (or planned arrival date)?

What PORT OF ENTRY did you arrive in Canada (or will arrive)?

Where do you live in Alberta?

When did you arrive in Alberta?

When do you intend to leave?

Have you ever lived in Canada before?

Yes No

If yes, where?

Previous Health Card Number:

Expiry Date:

MEDICAL (Mother)

Due Date:

Have you had a previous C-Section?

Yes No

Have you seen a provider/specialist for prenatal care in Canada?

(If yes - you must see OB for prenatal care)

Yes No

Any other medical issues:

Central Triage payment processing for uninsured and birth tourist patients receiving care in Alberta.

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