Ontario · adult pre-visit intake

Men’s health assessment.

A confidential, structured questionnaire for professional review. It does not diagnose a condition, choose a medication, or guarantee treatment.

About 4–5 minutes

Simple questions, useful context.

Choose the closest answer. You only need to type details when they are helpful for the healthcare professional.

18+ onlyConfidentialProfessional review required

Privacy & consent

Your answers are collected to coordinate and support professional review. Full health answers stay in the secure backend; notification emails contain only a reference number and care area. Read the privacy notice.

About youBasic information needed to coordinate care.

Full nameEmailPhone optionalAge range

Are you currently located in Ontario?

A regulated professional must confirm your identity and location before providing virtual care.

Your concernChoose the closest description.

What would you like to discuss?How long has this concern been present?How often is the concern present?Have you discussed this concern with a healthcare professional before?

Medical historyBroad health history helps the professional review your concern safely.

Do you have any ongoing medical conditions or significant past surgeries?Have you been admitted to hospital or visited an emergency department in the last 12 months?Do you have a regular family doctor, nurse practitioner, or other primary-care provider?

Medicines & allergiesProvide a short medication list only when relevant.

Do you take any prescription medicines regularly?Do you have any medication allergies or previous serious medication reactions?

Final notes & consentReview these acknowledgements before submitting.

Anything else the healthcare professional should know? optionalI confirm I am 18 years of age or older and I am submitting this information for myself.I understand what information is being collected and why, and I consent to RefyllRx using it to coordinate and support professional review. I may choose not to submit this form.I understand that my identity must be confirmed before virtual care is provided.I understand that my current location must be confirmed before virtual care is provided.I understand this form is not monitored for emergencies and I should call 911 or seek urgent care for severe or rapidly worsening symptoms.

Submitting this form does not create a clinician-patient relationship and does not guarantee treatment or a prescription.