Patient Intake Form

Complete Your Patient Intake

Streamline your visit to Whitby Clinic with our digital intake process

📍 7-3500 Brock Street North, Whitby. L1R 3J4📞 +1 905 430 7774

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

+1 905 430 7774

📧

Email

info@eclatmedical.com

📍

Address

7-3500 Brock Street North, Whitby. L1R 3J4

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 +1 905 430 7774 and we'll be happy to help or take your information over the phone.