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New Patient Intake Form - Dr. Ling Chen
We only accept those who currently Do Not have a Family Physician.


Seymour Health Centre
1530 W 7th Ave,
Vancouver BC V6J 1S3

Please note this is for setting up an initial consultation with a new provider. This does not indicate that the provider has taken you on as a patient. This is a consultation to ensure that you as the patient, and the provider are a good fit for one another for your ongoing healthcare needs.

Consultations are scheduled in order of applications received.

The initial consultations will be held in-person.
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Email *
Who referred you to Dr. Chen? (include any person or organization)
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Your First Name *
Your Last Name *
Date of Birth *
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Phone Number (best number to reach you) *

Your COMPLETE Address (Please include your apartment number and postal code)

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Occupation *
Gender (Legal Sex at Birth) *
Gender Identity *
Do you currently have a GP? *
List any medical problems other doctors have diagnosed (past, chronic, ongoing, new, surgeries)
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List all medications (prescriptions as well as non-prescribed such as vitamins, etc)
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Family history of medical problems

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Allergies *
Please list your most concerning health issues at this time
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Over the past 12 months, have you seen a doctor and if so, for what concerns?
Do you currently have any medical/legal, ICBC, WorkSafe or other issues we should be aware of?
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Lifestyle
Do you smoke? If so, how many packs per day for how many years? Ex-smoker?
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Do you drink alcohol? If so, how many drinks per week?
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Do you use any recreational drugs? If so, which ones and how often per week?
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Do you exercise? If so, how many times per week?
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Is there anything else you would like us to know about your health? If yes please explain:
Appointments
For all appointments, including the initial consultation, please arrive 10 minutes early to your scheduled appointment, whether the appointment is held virtually, telephonically, or in-person, in order to guarantee being seen.
Missed Appointments
Becoming a patient of Seymour Health Centre and Dr. Ling Chen's practice, requires you consent to the following clinic policies regarding missed and/or late cancelled appointments.
I consent to Seymour Health Centre’s late cancellation policy (< 24 hours notice) and agree to pay $89.90 for a regular visit, follow-up visit, and telehealth/virtual visit if I do not show up for an appointment or I cancel within 24 hours.
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I consent to a PharmaNet search by Dr. Ling Chen at Seymour Health Centre when deemed necessary. PharmaNet is a province-wide network that links all pharmacies in B.C. to a central data system. For more information on PharmaNet: https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/pharmanet
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Communications
While the provider will attempt to respond to all telephonic and electronic messages within 1-2 business days, please allow up to 72 hours for a response. For urgent care needs, please visit our Urgent Care Centre - open 7 days a week, 365 days of the year.
Forms
Any forms requiring completion by the provider should be submitted at least 1 week in advance. Whenever possible, early submission of the form(s) is highly recommended, if you wish to have completed in a timely manner. There is a fee for completing forms and doctors' notes.
Appendix - Risks of using electronic communication
The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use electronic communications).However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications:
• Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
• Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
• Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.
• Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
• Electronic communications maybe disclosed in accordance with a duty to report or a court order.
• Video conferencing using services such as Skype or FaceTime may be more open to interception than other forms of videoconferencing.
If the email or text is used as an e-communication tool, the following are additional risks:
• Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
• Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.
Conditions of using the Services
• While the Physician will attempt to review and respond in a timely fashion to your electronic communication, the Physician cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.
• If your electronic communication requires or invites a response from the Physician and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
• Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the Physician’s electronic communication and for scheduling appointments where warranted.
• Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.
• The Physician may forward electronic communications to staff and those involved in the delivery and administration of your care. The Physician might use one or more of the Services to communicate with those involved in your care. The Physician will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.

• You and the Physician will not use the Services to communicate sensitive medical information about matters specified below: Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, Substance abuse
• You agree to inform the Physician of any types of information you do not want sent via the Services, in addition to those set out above. You can add to or modify the above list at any time by notifying the Physician in writing.
• Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes.
• The Physician is not responsible for information loss due to technical failures associated with your software or internet service provider.

Instructions for communication using the Services
To communicate using the Services, you must:
• Reasonably limit or avoid using an employer’s or other third party’s computer.
• Inform the Physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.
If the Services include email, instant messaging and/or text messaging, the following applies:
• Include in the message’s subject line an appropriate description
of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message.
• Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician.
• Ensure the Physician is aware when you receive an electronic communication from the Physician, such as by a reply message or allowing “read receipts” to be sent.
• Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
• Withdraw consent only by email or written communication to the Physician.
• If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.
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