New Patient Intake Form

We encourage you to use Health Services as your primary point of medical/health care while at university, especially, if you do not have a family physician in Kamloops. We do work closely as a team, so any practitioner can help you. Please ensure TRU Medical Clinic is named as your primary care clinic if you go to the hospital, lab or x-ray departments, and results will be forwarded here to your medical record.

Thompson Rivers University (TRU) collects, uses, discloses and retains personal information in compliance with the BC Freedom of Information and Protection of Privacy Act (the FIPPA). 

Your personal information is being collected and will be used for the purposes of your medical assessment and treatment, to administrate your medical care, and communicate with you. 

The TRU Medical Clinic collects the following personal information about you: identification, contact information, student number, health information, emergency contact details, gender identity, healthcare number, date of birth, billing information, and if you are an international student your home country. The collection of this information is permitted under section 26(c) of the FIPPA, and will be retain in accordance with TRU’s Records Retention/Destruction Policy.

Under section 33.1 (1)(b) of the FIPPA, TRU may disclose relevant personal information to third parties to provide medical referrals to other health care professionals, and facilitate direct billing with your medical insurance provider. As required under this section of the FIPPA, by signing this form you are consenting to the disclosure of your personal information for these purposes.

The Province of British Columbia has established the provincial pharmacy network and database known as “PharmaNet” pursuant to section 37 of the Pharmacists, Pharmacy Operations and Drug Scheduling Act, R.S.B.C. 1996, c. 363, and which may be continued pursuant to the section 13 of the Pharmacy Operations and Drugs Schedule Act, S.B.C., 2003, c. 77 should be proclaimed in force during the term of this Agreement.

I authorize TRU Medical Clinic Staff and persons directly supervised by the physician to access my personal health information contained within PharmaNet for the purpose of providing therapeutic treatment or care to me, or for the purpose of monitoring drug use by me.

I understand that withdrawal of this consent must be in writing and delivered to the above-mentioned clinic.

Please note that once you are no longer a student or employee of TRU, you will not be able to access the clinic; however, your records will be available to your next health care practitioner with the completion of a Consent to Release Medical Information form, which is initiated by you and your practitioner and sent to our clinic.

Please ensure you arrive on time for your doctor’s appointment and cancel with at least 24 hours’ notice. We work really hard to provide timely and quality care to as many people as possible. If you miss your appointment or do not cancel within 24 hours, you will be charged a $40 fee that must be paid in order to book a future appointment. 

Please note, if you require forms filled out there are fees for our time, as MSP does not cover these costs. The following outlines all the form service fees: