Patient Intake Form

Complete Your Patient Intake

Streamline your visit to Barrie with our digital intake process

📍 320 Bayfield St, Unit M108B, Barrie, ON L4M 3C1📞 +1 (705) 555-0123

Digital Convenience

Complete your intake form online from the comfort of your home. Save time during your visit.

HIPAA Compliant

Your personal health information is protected with bank-level security and encryption.

OSCAR EMR Integration

Your information seamlessly integrates with our medical records system for efficient care.

Before You Begin

Have Ready:

  • • Health card number and version code
  • • Current medications list
  • • Emergency contact information
  • • Insurance information (if applicable)

Form Features:

  • • Save progress and resume later
  • • Step-by-step guidance
  • • Secure data transmission
  • • Mobile-friendly interface
1

Demographics

2

Contact Info

3

Emergency Contact

4

Medical Info

5

Consent

12% Complete

Step 1: Demographics

Please provide your basic information

Need Help?

Our team is here to assist you with the intake process.

Contact Our Office

📞

Phone

+1 (705) 555-0123

📧

Email

info@eclatmedical.com

📍

Address

320 Bayfield St, Unit M108B, Barrie, ON L4M 3C1

Frequently Asked Questions

Can I save my progress?

Yes, you can save your progress at any time and resume later from any device.

Is my information secure?

Absolutely. We use bank-level encryption and comply with all HIPAA requirements.

Do I need to print anything?

No, everything is digital. Your information will be available to our staff during your visit.

What if I have technical issues?

Call our office at +1 (705) 555-0123 and we'll be happy to help or take your information over the phone.