Welcome to The Borough Health & Wellness!

Help Dr. Dydynsky prepare for your visit by completing this short mandatory intake form.

First Name *

Last Name *

Date of birth *

Phone *

Email *

Full Address *

Preferred Pharmacy *

Health card number (including the last two letters): *

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Email *

Do you need your past medical records transferred from your previous doctor? *

Yes

Tell Us Anything Else *

I’m open to receiving supportive updates and information that can help me better understand my symptoms and the wellness options available to me. I can unsubscribe at any time. *

Yes

For clinic use only. Your responses are confidential and help our team at The Borough provide care that’s tailored to your wellness needs.