New patient intake

Register as a new patient

Joining iCollab Healthcare? Complete the intake form below and our team will be in touch to confirm your registration and next steps.

Two ways to complete it

Fill it out online, or download & print

This is a detailed form. Prefer paper? Download the full package — intake form plus consent & policies with a signature page — complete it by hand, and bring it to the clinic.

Download & print (PDF)

Before you start

A few things to know

Have your Personal Health Number (PHN) handy.
If you have a current or recent family physician, share their details so we can request your records.
Registering your whole family? Check the box in the form — each person still needs their own form, and we'll guide you.
Our team will call you to confirm registration and next steps.
Your information is handled per BC privacy law (PIPA).

Prefer not to enter your full history online? Use the Download & print option above and bring the completed form to your clinic.

Patient information

Given name *

Last name *

Personal Health Number (PHN#) *

Gender *

Age *

Date of birth *

Contact information

Home address *

Mobile phone number *

E-mail address *

Emergency name and number *

Occupation

Occupation *

Work phone *

Referral information

Who referred you to us *

Where did you hear about us *

Family members

Family members joining at the same time

Current family physician

If you have a current or recent family physician, please share their details so we can request your records. Leave blank if not applicable.

Physician's name

Clinic name and address

Phone and fax number

Medical history

If a section doesn't apply to you, please write None.

Current medical conditions *

Past medical conditions *

Family history (relation, condition, year) *

Social history (alcohol, nicotine, cannabis, drug use — amount per week/month/year) *

Surgical history and year *

Allergies

Medication allergies (and reaction) *

Food allergies *

Current medications

Current medications and dose *

Insurance / legal claims

Any current ICBC, WSBC, or Medical-Legal claims ongoing? *

Your clinic

Preferred clinic *

Policies & consent

Please review our Informed Consent & Clinic Policies before submitting. This agreement covers our services, confidentiality and electronic communications (per CMPA guidelines), payment/MSP, and our zero-tolerance policy on abusive conduct.

It also notes that your physician and the clinic may use artificial intelligence (AI) tools to assist with your care — for example, clinical scribing and documentation, drafting and scripting, and administrative tasks that improve the efficiency and quality of care. These tools support, and do not replace, your physician's clinical judgement.

Read / download Consent & Policies (PDF)

Signature

Type your full legal name and today's date, then draw your signature in the box below. Together these form your binding electronic signature for the consent and policies above.

Full legal name (signature) *

Date *

Draw your signature *

Sign here

* indicates a required field. Submitting does not guarantee registration; our team will confirm. If this is an emergency, call 911.