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Register For Family Physician
New Patient Intake Form
Last Name
First Name
Date of Birth
Health Card No
Mobile
Telephone
Email
Medical History
Current Medications
Do you currently have family doctor?
No
Yes
If yes, name of current family doctor:
Phone
Fax
Reason for switching
I understand the information will be used to assess priority of acceptance based on medical needs and clinic capacity. I understand this is not a formal acceptance into the practice. I provide consent to receive phone calls and text message regarding clinic update.
Submit
