Alliance MDS

Name *

(legal name as it is listed on your health-card)

First Name

Last Name

Are you right or left-handed? *

Right

Left

Ambidextrous

Primary phone number *

(###)

###

####

Is your primary phone a cell phone? *

Yes

No

Secondary phone number

(if applicable)

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have already scheduled an intake appointment for ... *

Only individuals with who have booked an intake appointment should complete this form. Any other submissions will be deleted immediately without review.

MM

DD

YYYY

Appointment start time *

Hour

Minute

Second

AM PM

Email consent *

We use email as a fast, clear, and largely reliable way of communication. May we include health information when emailing you? Sample messages that include health information would be messages to ask you to book a follow-up appointment, to let you know your results are normal, or to share details of a referral to a third-party. For clarity, we do not send marketing newsletters or sell your email address to third parties. Please see below for a discussion of the risks, conditions, and instructions for email. *Email Communication* Risks of using email Transmitting patient information by email poses several risks of which patients should be aware. You should not agree to communicate with us via email without understanding and accepting these risks. The risks include, but are not limited to, the following: - The privacy and security of email communication cannot be guaranteed. - Employers and online services may have a legal right to inspect and keep emails that pass through their system. - Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent. - Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer. - Email can be forwarded, intercepted, circulated, stored or even changed without our knowledge or permission. - - Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients. - Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace. - Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties. - Email can be used as evidence in court. *Conditions of using email* We will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of email communication. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions: -Emails to or from the patient concerning diagnosis or treatment may be made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails. - Email communication is not an appropriate substitute for clinical examinations. The patient is responsible for following up with our emails and for scheduling appointments where warranted. - If the patient’s email requires or invites a response from us and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond. - We are not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider. * Instructions for communication by email* To communicate by email, the patient shall: - Limit or avoid using an employer’s or other third party’s computer. - Review the email to make sure it is clear and that all relevant information is provided before sending to us, including the purpose of the email and the name of the patient. - Take reasonable precautions to preserve the confidentiality of emails. - Withdraw consent only by email or written communication to us.

Yes

No

Kindly review and acknowledge the following (Risks Involved With Virtual Appointments) *

COVID-19 is placing stress on Canada's public health system. We are starting to offer virtual care to make sure that we can continue to care for our patients safely and effectively. This means that we will be using video and audio technologies for some patient visits rather than asking patients to come into our office. Some of these technologies are provided by the Province. Others have been provided by vendors like Google, or Apple to help make discussions with your care provider as easy as possible during these difficult times. Some health concerns can be addressed with virtual care alone, but in some cases your doctor may ask you to visit a hospital or other health care facility if necessary, for a physical examination. We do our best to make sure that any information you give to us during virtual care visits is private and secure, but no video or audio tools are ever completely secure. There is an increased security risk that your health information may be intercepted or disclosed to third parties when using video or audio communications tools. To help us keep your information safe and secure, you can: - Understand that emails, calls, or texts you receive are not secure in the same way as a private appointment in an exam room. - Use a private computer/device (i.e., not an employer's or third party's computer/device), secure accounts, and a secure internet connection. For example, using a personal and encrypted email account is more secure than an unencrypted email account, and your access to the Internet on your home network will generally be more secure than an open guest Wi-Fi connection. - You should also understand that electronic communication is not a substitute for in-person communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed (including for any urgent care that may be required). - If you are concerned about using video or audio tools for virtual care, you can ask our office to postpone your appointment until after the Covid-19 crisis has resolved or we can let your referring doctor know that you would like to visit a different healthcare provider where you can be seen in person. However, please note that visiting a health care provider in person comes with a higher risk of coming into contact with COVID-19 and the possibility of spreading the virus. - By providing your information, you agree to let us collect, use, or disclose your personal health information through video or audio communications (while following applicable privacy laws) in order to provide you with care. In particular, the following means of electronic communication may be used: email, videoconferencing, text messaging, website/portal.

Yes (I have reviewed and acknowledged the above)

Kindly review and acknowledge the following (Dr. Danny Monsour is not a Magenta Physician) *

1. Magenta Health Inc. ("MHI") is a medical management company that owns and operates one or more clinics under the brand name MAGENTA HEALTH (the "Magenta Health Clinics"). 2. MHI is not permitted to, nor does it, provide medical services to patients, including myself. 3. Physicians practicing at Magenta Health Clinics (such as the physician you are here to see today) are qualified independent medical practitioners providing medical services to patients directly, or via a medicine professional corporation as authorized under the laws of the Province of Ontario. 4. Physicians practicing at Magenta Health Clinics may receive some administrative assistance or support, but for the most part, operate their own practice. 5. If I consented to email communication, I have read and understood the attached discussion of the risks of email communication. 6. I understand that I will be contacted via the information above and confirm that my contact information is correct and up-to-date.

Yes ( I have reviewed and acknowledge the above)

I understand this form will NOT be reviewed by a medical professional prior to my scheduled appointment *

Yes

I understand I will not be a patient until after my appointment has been completed *

Yes

Are you experiencing any of the following on an ongoing basis? *

Check all that apply

Fevers/chills

Night sweats

New fatigue

Unintentional weight loss

Chest pain

Shortness of breath

Ongoing/Persistent cough

Coughing up blood

Change in bowel or bladder habits

Nausea/vomiting

Diarrhea

New or unusual headaches

Numbness/tingling

New weakness

New joint pains or stiffness

Sudden change in vision

Sudden change in hearing

Easy bruising or bleeding

Change in mood

Thoughts of self-harm

None of the above

Do you have kidney disease or failure? *

Yes

No

Do you take any blood thinners? *

Yes

No

Do you have, or have you ever had, any of the following medical conditions? *

Check all that apply

High blood pressure

Asthma

Stroke/Brain aneurysms

Heart Problems

Kidney stones

Depression/Anxiety

Head injury/Concussion

None of the above

Is your menstrual cycle regular or irregular? *

Regular

Irregular

Not Applicable

Are you pregnant or planning to be soon? *

Yes

No

N/A

Have you been diagnosed with sleep apnea? *

Yes

No

Do you practice Mindfulness/Meditation? *

Yes

No

Do you have a private drug coverage plan? *

Yes

No

Are you married/common-law? *

Yes

No

Children *

Yes

No

Does anyone in your family have any of the following? *

Check all that apply

Migraine/Other Headache disorders

Neurological disorders including stroke

Unexplained miscarriages

Other genetic conditions

None of the above

1. Feeling nervous, anxious, or on edge *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2. Not being able to control or stop worrying *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3. Feeling down, depressed or hopeless *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4. Little interest or pleasure in doing things *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

1. When you have headaches, how often is the pain severe? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

2. How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

3. When you have a headache, how often do you wish you could lie down? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

5. In the past 4 weeks, how oftenhave you felt fed up or irritated because of your headaches? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

6. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)