Welcome to our practice! Please fill out the information below as completely as possible. If you do not know exact dates, please estimate to the best of your ability
At what age did your child do the following?
Does your child regularly take any medications? Please include inhalers and vitamins on this list
Additional food allergies
Below is a list of potential medical problems or chronic diseases that can affect children. Please Select the medical problems that affect YOUR CHILD and provide details as indicated. Please provide as much information as you can recall.
Add Medical Problems
If other medical problems not listed? Please provide below.
Below is a list of potential medical problems or chronic diseases that may affect people in your family. Please select any conditions in the family and give additional details as you are able.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2023 Hush Communications Canada Inc.