Member Emergency Profile

Personal Information

Date of Birth:

30/03/1966

(dd/mm/yyyy)

Health Card Number: 

2121 359 158 HK

Full Name: 

Mrs.
Leanne
Beattie

Phone: 

+15196718717

Home Address: 

{“street_address”:”46 Dennis Ave”,”street_address2″:””,”city_name”:”London”,”zip”:”N6P 1B9″,”country_select”:”CA”,”state”:”ON”}

Blood Type: 

O-Positive

Blood Pressure: 

–

Health Insurance: 

Yes

Travel Insurance: 

Yes

Emergency Contact Details

Primary Contact

Name: 

Darryl
Beattie

Phone: 

+15196150469

Secondary Contact

Name: 

Tami
Gibb

Phone: 

+12264487765

Family Doctor or Clinic Contact

Type: 

Doctor

Name: 

Dr Tunde Sonuga

Phone: 

+15196525996

Medical Conditions

Medical Conditions

None Listed

Other Medical Conditions

None Listed

Medication Information

Medication List

None Listed

Current Medication Details

None

Known Medication Allergies

Medication Allergies

None Listed

Other Medication Allergies

None

Other Allergies

Allergies

None Listed

Other Allergy Details

None

General Medical Information

Miscellaneous

Do you smoke: 

No

Do you vape: 

No

Do you wear glasses: 

No

Do you wear contacts: 

No

Do you have cataracts: 

No

Are you pregnant: 

No

Other Medical Details

Vaccination Information

Common Vaccinations Details

Hepatitis A/B: 

Yes

Influenza: 

Yes

Pneumonia: 

No

Shingles: 

No

Tetanus: 

Yes

Other Vaccination Details

COVID Information

COVID Vaccination

Have you had COVID:

Yes

Have you been vaccinated: 

Yes
01/01/1970
Moderna, AstraZeneca

Covid Vaccination Reactions or other Details

COVID Booster

Have you had a COVID Booster:

Yes

Booster Type and Date: 

Pfizer
01/01/1970

Existing Medical Conditions Preventing Vaccination

No