Intake Salutation * Mr. Mrs. Ms. Miss Name * First Name Last Name BC Care Card Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Email * Occupation Employer Work Phone * (###) ### #### Emergency Contact * Relationship * Emergency Contact Phone Number * (###) ### #### Whom may we thank for referring you to this office? Medical and Podiatry Information Family Doctor * Family Doctor Phone Number (###) ### #### Last Visit Height Weight Shoe Size Do you have diabetes? Yes No Any Family History of Diabetes? Yes No Thank you!
