Registration for access to a family doctor Centre de santé et de
Transcription
Registration for access to a family doctor Centre de santé et de
Registration for access to a family doctor (Guichet d’Accès pour clientele sans médecin de famille) Centre de santé et de services sociaux des Collines * Please fill in in BLOCK LETTERS * Persons aged 14 or older must complete this form by themselves; one for mis required for each person. Client Identification Health Insurance No. : Name : Given Name : Address : City : Postal Code : Telephone No. (Home): (Work) : (Other) : Location of CLSC : __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ _________________________ _____________________ ___ ___________________ Extension ________ _________________________ Cantley Chelsea Masham Val-des-Monts Date of registration : Date of birth : ____________________ (YYYY-MM-DD) Age : ____________________ Gender : female Male Preferred Language : French English Other : ____________________ Referral Origin of referral : User Network Professional Medical Clinic CSSS (specify) ____________________________ Other (specify)___________________________ Last Family Doctor : _________________________________________ Last visit : __________________ Details (as required) : _______________________________________________________________________________ _______________________________________________________________________________ Evaluation Do you have any diagnosed illnesses ? Specify :___________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ How is your state of health ? : Chronic Under Treatment Uncontrolled In Remission Controlled or Stable Other (specify) : _______________________ Do you take medications ? If so, specify : _______________________________________________________________ _______________________________________________________________________________________________________ Are you currently receiving care from a CLSC? specify : __________________________________________________________ _______________________________________________________________________________________________________ Are you being treated by a specialist ? If so, which one ? ___________________________________________________ Have you been hospitalized in the last two years ? If so, place and reason : __________________________________________ _______________________________________________________________________________________________________ Have you had surgery in the last 2 years ? If so, place and reason : _________________________________________________ _______________________________________________________________________________________________________ Did you visit an emergency room in the last year ? If so how many times ?___________________________________________ Do you have any health conditions and/or handicaps that limit your mobility ? If so, specify : _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Other comments : ________________________________________________________________________________________ _______________________________________________________________________________________________________ I hereby authorize the Guichet d’accès pour clientele sans médecin de famille to retain the information herein in a secure central bank, with the understanding that my application be kept in compliance with all confidentiality rules. I also authorize the CSSS des Collines to transmit such information for the purposes of providing the care of services required by my health condition to the physician who will agree to become my family doctor. This consent is valid for the duration of this request for services. Signature : If sent by mail : X___________________________________________________ (Signature required if not transmitted online) Date : ____________________________________ Guichet d’accès pour clientèle sans médecin de famille Centre de santé et de services sociaux des Collines 490 Route 105, suite 201 Chelsea (Québec) J0X 3G0 Guichet d’Accès pour clientèle sans médecin de famille au 819 459-1112 poste 2521 M:\Ressources humaines\Roxane\CLSC\Guichet_MedecinFamille_GACO\Formulaire_GACO_Anglais.docx