Pediatric Care

Specialized healthcare for children, ensuring a healthy start.

New Patient Registration

To make your visit as smooth as possible, please complete our Patient Screening Forms. This helps us provide you with the best care during your appointment.

Preventative Care

Stay healthy with regular check-ups, screenings, and vaccinations.

New Patient Intake Form

Please read carefully and answer appropriately

Patient Type

Existing Patients of Dr Amar and Dr Marwan New Patients

Existing Patient Form

First Name

Last Name

Health Card Number Choose a Doctor:

Dr. Marwan Matti Dr. Amar Alsalahi

Demographic

Application Date

Full Name

Date Of Birth

Health Card Number

Expiry Date

Full Address

Phone Number

(By entering this information you agree to us contacting you via phone, text message, or email)

Emergency Contact Information

Name

Phone Number

Relationship

(By entering this information you agree to us contacting your emergency contact via phone)

Do you speak English?

(If not, make sure you are accompanied by someone who does)

Yes No

Medical History

Do you have any allergies?

(Please provide details below)

Yes No

Do you suffer from (or previously suffered from) any of the following:

Diabetes

Asthma

Stroke

High Blood Pressure

Angina

Heart Attack

Cancer

Have you had any surgeries in the past?

Have you been in any major accidents?

Do you have any mental health conditions?

Substance Abuse

(Select all that apply)

Tobacco

Current Smoker Ex-Smoker

Alcohol

Marijuana

Other Substances

Screening History

Last PAP Smear

Results?

Have you received any vaccinations in the last 10 years?

Please list all medications you currently take

Please list all medications you have previously taken

Family Medical History

Diabetes

Asthma

Stroke

High Blood Pressure

Angina

Heart Attack

Cancer

Other

Doctors use an AI Scribe software to listen to conversations and record them to help with documentation. No biographical information is recorded with this software. Please ask the reception for more information if needed, if you do not agree to this, please inform the doctor during your visit.

Doctors are using a software called Ocean to contact you regarding appointments, follow-ups, and to send your investigation requests through emails or by texts. It is secure and encrypted. Thus, providing your email is important.