Medical Profile

Skip to content

Mission Hills Medical Clinic

Home
Talk to Doctor
Forms
- Patient Profile
- Mental Health Form
Medical Profile
- Clinical Services
About us
Contact

Name *

First

Last

Phone number *

Address *

Email *

Carecard Number *

Drug Allergies *

Pharmacy Name *

Occupation *

Marital Status *

Childhood Immunizations up to date *

Medical History *

Surgical History

Family History-High Blood Pressure, Hypertension, Diabetes, Heart Disease, Cancer, Mental Health-Type in conditions below *

If there is no family history, see below

Family History

Please select appropriate box, you can select more than one

Smoking Status *

Vaping Status *

Alcohol Consumption *

Cannabis Consumption *

Drug Use *

Exercise *

Permissions *

Yes, I give consent for Electronic Communications
Yes, I give consent to print Pharmanet

Mutual respect

We are concerned about each patient and we do our best to give quality and caring medical care. In return we expect visitors to our clinic to be courteous and use polite language.

Patient Resources

General patient resoures

Find Us

Address

107-32471 Lougheed Hwy
Mission BC V2V 0C8
Phone: 604-826-7751 Ext 0

Hours

Monday to Friday 8am-5pm

Banner photo by Avel Chuklanov on Uns plas h

Home
Talk to Doctor
Forms
Medical Profile
About us
Contact