New Patient Intake Form

TRU Medical Clinic: New Patient Form

Page 1

Dear Student: Welcome to Thompson Rivers University Health Services! 

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.

Client Information











Contact Information








Details of the visit







Past Medical History



Medications

Privacy Notification and Consent

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.

For further information about this privacy notice and consent, please contact the Medical Office Assistant at the TRU Medical Clinic, by calling 250-828-5126, or by mail at: 805 TRU Way, Kamloops, BC V2C 0C8. Alternatively you may contact the Privacy Office at privacy@tru.ca. This form will be retained as part of your medical file.
Access after graduation/post-TRU employment

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.
Missed Appointments and Form Fees

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:

No MSP - $50
Accessibility Forms - $40
Drivers Medical - $100
Forms (per page) - $20
Doctor's Sick Note - $20
Work/Sports Physical Exams - $50
Liquid Nitrogen (cosmetic) - $10



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