Become a new patient

Apply to become a new patient:

PLEASE NOTE: Completing and submitting this patient intake form does not automatically make you a patient at this clinic. There are limited openings at this time and only accepted patients will be contacted to schedule an initial meet and greet with a family physician. Please do not transfer your medical records until after you have been accepted as a patient.
Incomplete forms will not be considered.

Date: Last name:* Date of birth:* Gender: Home address: Phone number:*

Current family physician *

Please let us know if you currently have a family doctor assigned to you. If "Yes", specify the physician.

Yes

If yes, please specify:

First name:* Health card number:* Email:* Emergency contact (Name, relationship, phone): Do you have family members in the clinic? Current medications: Allergies:

Medical history (check all that apply)

Do you have a medical history? *

Yes

Surgical history (check all that apply)

Other surgeries:

Family history (check all that apply)

Social history

Insurance claims (active)

Do you currently have any active insurance claims? *

Yes

WSIB

Other

Patient declaration

Printed name of patient / Guardian:*

Signature (type name):*

Date signed:

Become a patient

Apply to become a new patient: