New Patient Registration — Living Spring Medical Clinic

Part 1 of 4

Patient Demographics

Last name

First name

Middle name

Preferred name (if different)

Date of birth

Gender

Alberta Personal Health Number (PHN) * Format: 12345-6789 (9 digits)

Physical address

City

Province

Postal code

Contact information

How to reach you

Emergency contact

Who should we call if needed

Contact name

Relationship to patient

Primary phone number

Part 2 of 4

Medical History Questionnaire

List all prescription medications, over-the-counter drugs, vitamins, and herbal supplements you currently take.

Current medications & supplements

Medication / supplement Dosage Frequency Reason

Allergies

None Yes — please list below with reaction

Personal medical history — check all that apply, past or present

If cancer, please specify type

Past surgeries / hospitalizations (year & reason)

Primary care pharmacy name & location

Part 3 of 4

Consent to Care & Scope of Practice

This section outlines the framework of your care at Living Spring Medical Clinic. Please review before signing below.

Scope of practice of a Nurse Practitioner (NP)

In Alberta, Nurse Practitioners are independent primary care providers registered with the College of Registered Nurses of Alberta (CRNA). They are fully authorized to:

Diagnose and treat acute and chronic illnesses.
Order and interpret screening tests, lab work, X-rays, MRIs, and ultrasounds.
Prescribe medications, including controlled substances and narcotics.
Refer patients directly to medical specialists and community health programs.

Patient rights and responsibilities

Mutual respect — we provide a safe, non-judgmental environment and expect patients to treat our staff with courtesy and respect.
Active collaboration — you have the right to make informed choices about your care; your NP will discuss treatment benefits, risks, and alternatives with you.
Accuracy — you agree to provide honest, complete information about your health history and lifestyle to ensure safe prescribing and treatment.

Patient signature (type full legal name)

Date

Part 4 of 4

Third-Party Disclosure Authorization

Your health privacy is strictly protected under Alberta's Health Information Act (HIA). Clinic staff cannot discuss your scheduling, medical conditions, test results, or treatments with anyone else unless you provide explicit permission below. This authorization remains valid until you revoke it in writing, and you can change or cancel it at any time by contacting the clinic. Leave this section blank if you don't wish to authorize anyone.

Authorized individual 1

Name

Relationship

Phone

Scheduling / billing only Full medical information

Authorized individual 2

Name

Relationship

Phone

Scheduling / billing only Full medical information

Patient signature (type full legal name)

Date

Part 5 of 5

Identity Verification

To protect your health record, please take a clear photo of your driver's license or passport. The name on it must match the first and last name you entered above. A staff member will confirm this before your registration is finalized.

Photo of driver's license or passport On a phone, this opens your camera directly. On a computer, you can upload a photo or scan instead. JPG, PNG, or WEBP, up to 8 MB.

Please add a photo of your ID before submitting, and make sure the name on it matches what you entered above.