Virtual Care Form - Medical Care

I am an active patient or have been referred. *

I am an active patient
I have been referred

Name *

First

Last

Email *

Email

Confirm Email

Preferred Appointment Day(s) *

Preferred Appointment Time *

Morning
Afternoon

Age

Date of Birth//

Health Card Number *

Gender

Phone Number *

Occupation

Referring Doctor

Pharmacy Name

Pharmacy Fax Number

Is this a First Visit or a Follow-Up Visit? *

First Visit
Follow Up Visit

Please describe the affected area on your body *

Upload any photos of affected area

Click or drag files to this area to upload. You can upload up to 5 files.

To provide you an accurate diagnosis, good images are essential. Please do the following: 1. 2 photos for each area - one from arms length, one close up such as hand length 2. add a ruler to the photos or a coin like a penny 3. label the photos with site 4. check that they are sharp and in focus 5. upload with your Virtual Care form

What is your skin and/or hair concern about this area? *

How long have you had this problem? *

Is it itchy?

Extremely
Yes
A little
Not at all

Is it painful?

Extremely
Yes
A little
Not at all

What makes it worse?

What makes it better?

What treatments have you used?

Did any of those treatments help?

Do you have a history of skin and/or hair problems?

Do you have any family members with skin and hair problems?

Do you have any other medical problems? If so, please elaborate.

What medicines do you take?

Do you have any known allergies to medicines or chemicals?

Which dermatologist have you been referred to? *

Dr. Tan
Other
None

I Understand that this method of communication is not secure in the same way as a private appointment in an exam room. *

Yes, I agree

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