Secure Registration – Page 1 of 6

The Elizabeth Bagshaw Clinic respects and upholds an individual's right to privacy and to protection of personal information. We are committed to ensuring compliance with all relevant legislation.

You will need a valid email address in order to complete this form. This is required so that we can communicate with you via the Medinet secure email system.

Please enter the following information:

Procedure covered by:
               
Abortion is covered by MSP in BC
Care Card Number:
  
If you do not have a valid care card you will have to pay for your procedure
Family Name:
As it appears on your care card
First Name:
As it appears on your care card
What name do you go by:
Preferred pronoun:
Birth Date:
 
                
 
Have you been to the clinic before?
 Yes    No    Don't know/not sure
When was the last time?

Keyword:

Please create a keyword to protect your account. It can be anything you want — a name,
a number, etc. — something that you are going to remember.
Keyword
If you phone us, we'll ask you for this keyword to ensure that it is you phoning,
so that no one else can get access to your information.

Secure Registration – Page 2 of 6

Contact Information

Address:
Address 2:
City:
Province:
Postal code:
Primary Phone:
Can we leave a message saying "Beth called" ?  
 Yes   No 
Alternate Phone:
Referred by:
Can you communicate in English?
 
 
Yes    No
We will arrange and pay for an interpretor for you. Otherwise, you must be sufficiently fluent in English as you will be on your own during the procedure.
What language do you speak:
Name of escort (if any):
 
 

Due to our small waiting room you are asked to only have one person accompany you. You and your escort must provide picture ID to enter the clinic. The escort will not be accompanying you into the procedure or recovery room.

Secure Registration – Page 3 of 6

Reproductive History (all information provided is strictly confidential)

All fields are mandatory. For your surgical safety the information you provide needs to be accurate or it may delay your surgery/care.

1.
What type of appointment do you need?
2.
What was the first day of your last normal menstrual period?
  
Leave blank if not appropriate or you don't know.
 
 
3.
Was this a regular menstrual period for you?
Yes          No   
4.
Do you have a regular menstrual cycle of 25 - 35 days?
Yes          No   
5.
With this pregnancy, where did you have your
positive pregnancy test?
Home      Doctor
Not tested
 
When?
  
6.
Were you using birth control when you got pregnant this time?
Yes          No
 
What kind?
7.
Do you have an IUD in place now?
Yes          No
8.
Has a doctor ever told you that you have fibroids (bumps or masses) in your uterus?
Yes          No
9.
Have your ever had any tubal or ovary problems?
Yes          No
 
What year was it?
 
Please tell us what treatment you had
10.
Have your ever had pelvic inflammatory disease (PID)?
Yes          No
 
What year was it?
 
Please tell us what treatment you had.
11.
Have your ever had an abnormal PAP test result?
Yes          No
 
What year was it?
 
Which followup tests did you have?



Colposcopy
Cryotherapy
Repeat PAP
12.
With this pregnancy, have you had an ultrasound?  
Yes          No
 
Where did you have your ultrasound?
 
Address
 
When was it?
  
13.
Have you been pregnant before?
Yes          No
 
How many times have you been pregnant?
Including miscarriages but not this pregnancy.
 
How many vaginal deliveries?
 
First pregnancy
 
Second pregnancy
 
Third pregnancy
 
Fourth pregnancy
 
Fifth pregnancy
 
Sixth pregnancy
 
Seventh pregnancy
 
Eighth pregnancy
 
Nineth pregnancy
 
Tenth pregnancy
14.
Have you had a C-Section?
Yes          No
 
How many times?
 
When were they?
1.
 
 
2.
 
 
3.
 
 
4.
 
 
5.
15.
Have you had a still birth?
Yes          No
16.
Have you had an ectopic pregnancy?
Yes          No    Don't know
An ectopic pregnancy is a pregnancy that is located outside the uterus (womb).
 
When?
17.
Have you had an abortion before?
Yes          No
 
How many times?
 
When?
1.
 
 
2.
 
 
3.
 
 
4.
 
 
5.
18.
Have you had a miscarriage before?
Yes          No
 
How many times?
 
You must have a pregnancy test done, before you can book an appointment with the clinic.

Secure Registration – Page 4 of 6

Medical Information (all information provided is strictly confidential)

All fields are mandatory. For your surgical safety please be as accurate as possible.

1.
What is your height?
 ft.  in. or  cm.
2.
What is your weight?
 lb. or  kg.
 
Is your shirt collar 16 inches / 41 cm or larger?

Yes          No
3.
Do you have any allergies?
Yes          No    Unknown
Including medication or food
 
Please list the allergies and any reaction.
eg. anaphylactic or rash
 
Do you have any reaction to latex?
Yes          No
Bandaids, latex gloves, balloons, condoms
 
Have you ever had an anaphylactic reaction to latex?
Yes          No
Wheezy, couldn't breathe or throat constriction.
 
 
4.
Have you ever had or do you suffer from:
All options must be answered.
Please choose yes or no.
a.
Asthma
Yes          No
 
Is this current or past?
Current    Past
 
Have you ever been hospitalized because of your asthma?
Yes          No
 
What was the treatment?
Oxygen    Intubated
 
Have you ever been treated for your asthma?
Yes          No
 
What medications did you take?
 
Do you use a puffer?
Yes          No
 
How often?
 
Are there any concerns or restrictions with your asthma?
b.
Diabetes
Yes          No
 
Are you on medications for your diabetes?
Yes          No
 
What medications and dose?
 
Please tell us more.
Type 1 or Type 2, frequency of self-testing, sliding scale, usual range of blood sugar levels.
 
Can we contact your doctor?
Yes          No
 
Name of Doctor                                                       Dr.
c.
Seizures
Yes          No
 
Have you been diagnosed with epilepsy?
Yes          No
 
When was your last seizure?
 
How often do you have seizures?
 
What type of seizures?
 
Are you on seizure medication?
Yes          No
 
What medications and dose?
 
What brings on your seizures?
 
Can we contact your doctor?
Yes          No
 
Name of Doctor                                                       Dr.
d.
Anemia (low iron)
Yes          No
 
Is this current or past?
Current    Past
 
Can we contact your doctor?
Yes          No
We will need a recent blood test result sent to us.
 
Name of Doctor                                                       Dr.
e.
Clotting / bleeding disorders
Yes          No
 
What is the name of your disorder?
 
Are you on medications for your disorder?
Yes          No
 
What medications and dose?
 
Can we contact your doctor?
Yes          No
 
Name of Doctor                                                       Dr.
f.
Heart disease / murmur
Yes          No
 
Do you have symptoms or physical restrictions?
Such as shortness of breath
Yes          No
 
Please tell us more.
 
Are you on medications for this?
Yes          No
 
What medications and dose?
 
How many tests or surgeries have you had for this problem?
 
1. Please provide details and if this was a surgery, did it fix the problem?
 
2. Please provide details and if this was a surgery, did it fix the problem?
 
3. Please provide details and if this was a surgery, did it fix the problem?
 
4. Please provide details and if this was a surgery, did it fix the problem?
 
5. Please provide details and if this was a surgery, did it fix the problem?
 
Can we contact your doctor?
Yes          No
 
Name of Doctor                                                       Dr.
g.
Other previous surgery
Yes          No
 
How many previous surgeries have you had?
 
1.                   Please provide details.
 
2.                   Please provide details.
 
3.                   Please provide details.
 
4.                   Please provide details.
 
5.                   Please provide details.
h.
Hepatitis A, B or C
Yes          No
 
Can we contact your doctor?
Yes          No
We will need a recent liver function test result sent to us before we can book you.
 
Name of Doctor                                                       Dr.
i.
Reaction to local or general anaesthesia
Yes          No
 
Please tell us more.
j.
Sleep apnea
Yes          No
 
Do you use a CPAP machine?
Yes          No
k.
Snoring
Yes          No
Do you snore loudly? Loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night.
l.
Fatigue
Yes          No
Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving or talking to someone)?

m.
Breathing Interruptions
Yes          No
Has anyone observed you stop breathing or choking/gasping during your sleep?

n.
High blood pressure?
Yes          No
Do you have or are you being treated for high blood pressure

o.
Vomiting
Yes          No
 
Please tell us more.
p.
HIV test in the last year
Yes          No
 
What was the result?
Pos          Neg
5.
Have you or anyone that you live with ever been told you have a bacteria that is 'resistant to antibiotics'.
Yes          No
such as MRSA (Methicillin-resistant Staph Aureus) or VRE (Vancomycin-resistant Enterococcus)
6.
Have you been treated in a hospital outside of Canada in the last 12 months?
Yes          No
7.
Have you spent more the 12 continuous hours as a patient in a hospital in Canada in the last 12 months?
Yes          No
8.
Do you have any other medical conditions?
Yes          No
 
Please tell us more.
9.
Are you taking any other prescription medications?
Yes          No
Including birth control pills
 
Please list all and what they are for.
eg. bipolar, anxiety, etc.
10.
Do you have problems walking?
Yes          No
 
Please describe.
Example: use cane or wheelchair
11.
Do you currently use any recreational or "street" drugs?
Yes          No
The use of recreational drugs such as heroin, cocaine, crack, crystal, marijuana, etc. may interact with the medications we give you to provide comfort during the procedure. Knowing all drug usage will ensure we can provide the best and safest care in our clinic.
 
Please check which ones.
Marijuana
Cocaine
Heroin
Ecstacy
Crystal Meth
Methadone
 
Other
 
Please tell us how you take the drugs.
 Smoke
 Snort
 IV
 Pill form
 Orally
 
How often do you take drugs?
 Daily
 Weekly
 Socially
 Rarely
12.
Is there any additional information you would like us to be aware of?
e.g. overnight hospital stays.

Secure Registration – Page 5 of 6

Your Preferred Appointment Times
Note: We will do our best to accommodate your preferred times, but your situation may dictate when we will have to see you.

Time Any Day Tuesday Wednesday Thursday Friday Saturday
Anytime
Morning
Afternoon

Secure Registration – Page 6 of 6

Your Email Information
Confidential Email
I authorize Elizabeth Bagshaw staff to respond to me via
secure Medinet Mail.
 
  Email address:
  Enter email again:

You must click on the Submit button at the bottom of the page to complete your registration

  • You will get an email from the clinic. The message will look like the example below.

  • Open the email from "Beth" - the name we use to better protect your privacy.

  • This email will contain a link to pick up your appointment information.

  • Check your "Junk mail" if you don't see a message from Beth.


 

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