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Exec Survey
Step
1
of
12
8%
Let's get started! Please fill out the following fields:
Name
(Required)
First & Middle
Last
Date of birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Current Address
(Required)
Please enter the current address you reside at.
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Let's start with your medical history.
Please list as many medical conditions you have been diagnosed with.
List
(Required)
Add
Remove
Are you currently taking any medications
If Yes, which medications are you taking?
Ext Medications
Yes
No
List
(Required)
Medication Name
Strength and Frequency (ie. 10mg daily)
Add
Remove
Are you currently taking any over-the-counter medications, natural products or supplements?
If Yes, which products are you taking?
OTC
Yes
No
List
(Required)
Product Name
Add
Remove
Do you have any allergies to any medications, both prescribed or over-the-counter?
Allergy
Yes
I have no known medication or drug allergies
List
(Required)
Allergy
Severity
Add
Remove
Do you have any other allergies, such as seasonal allergies, food allergies, or other non-medication allergies?
OTC Allergy
Yes
I have no known non-medication or non-drug allergies
List
(Required)
Allergy
Severity
Add
Remove
Have you had any prior surgeries or hospitalizations?
If you have, please describe below
Surgeries
Please describe your family medical history
Does anyone in your family have any medical conditions? If so, please describe them here.
Family history
This is your opportunity to introduce yourself to our specialists and our Allied Health Team.
Let us know what you would like us to be aware of with regards to your health or wellness goals!
Upload a photo of government issued ID (e.g. drivers license).
Please make sure
Your ID is valid and within the frame
Your information is clearly visible
File Upload
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Do you have a provincial health card?
(Required)
Yes
I do not have a provincial health card.
File Upload
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Please provide the health card number as it appears on the card
Do you have coverage for medications through a private insurance plan?
(Required)
Yes
No
Please make sure
Your card is valid
Within the frame
Your information is clearly visible
Front of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Back of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 5 MB.
Do you have additional coverage for medications through a 2nd private insurance plan?
(Required)
Yes
No
Front of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Back of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Please upload a selfie, ensuring your face is fully within frame, clearly visible, and not filtered in any way.
(Required)
Please make sure your face and shoulders are visible and well-lit.
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 5 MB.