What do you believe led to you relapsing this program? YOUR PHYSICAL HEALTH Clients must also have a valid Ontario Health Card before being admitted to the Program, or means to obtain required prescription medicine. Hope Acres will not be responsible to obtain/and or pay for prescribed medicine for Clients once he arrives at the Centre. Ministry Please indicate Health Card number below and attach photocopy of card/ of Health letter Health Card # ______________________________________________ Two Letter Version Code: ____ Expiry Date: __________ I have a history of: Yes No Yes No Epilepsy: Diabetes: Yes No B Yes No C Yes No Hepatitis: A- Yes No Yes No Cirrhosis: HIV Positive: Yes No Yes No STD: Emphysema/Lung Disease: Yes No Yes No Cardiac: Back Problems: Yes No Yes No Ulcers: Allergies: Yes No Yes No Vision Problems: Do you require Glasses? Yes No Dental Problems: Last Visit to the Dentist: ____________________ All dental concerns MUST be dealt with prior to admission to Hope Acres. Last to Doctor: ______________ Emergency Clinic: Walk-in Clinic: __________________
What do you believe led to you relapsing this program? YOUR PHYSICAL HEALTH Clients must also have a valid Ontario Health Card before being admitted to the Program, or means to obtain required prescription medicine. Hope Acres will not be responsible to obtain/and or pay for prescribed medicine for Clients once he arrives at the Centre. Please indicate Health Card number below and attach photocopy of card/ Ministry of Health letter Health Card # ______________________________________________ Two Letter Version Code: ____ Expiry Date: __________ I have a history of: Epilepsy: Yes No Diabetes: Yes No Hepatitis: A- Yes No B Yes No C Yes No Cirrhosis: Yes No HIV Positive: Yes No STD: Yes No Emphysema/Lung Disease: Yes No Cardiac: Yes No Back Problems: Yes No Ulcers: Yes No Allergies: Yes No Vision Problems: Yes No Do you require Glasses? Yes No Dental Problems: Yes No Last Visit to the Dentist: ____________________ All dental concerns MUST be dealt with prior to admission to Hope Acres. Last to Doctor: ______________ Emergency Clinic: Walk-in Clinic: __________________
2017-Client-Application-Package-Complete-15.docx