Patient Enrolment and Consent to Release Personal Health Information

Patient Enrolment and Consent to Release Personal Health Information

Please complete a separate form for each patient that is 16 years old or more.
Before completing the form below, please review the following policy items of Compass Medical Clinic. Your understanding and agreement to these items is necessary before beginning our enrolment process.
Our physicians work together with nurse practitioners (NPs) to deliver comprehensive care. All medical concerns are reviewed by our physicians, however, you may often be able to secure an appointment with one of our nurse practitioners earlier than with your physician.
Our administrative team works hard to meet our patients’ needs in a timely manner. To optimize this, email is our primary means of communication between patients and our clinic staff. We reply to emails during our business hours (Monday to Friday, 9:00am to 5:00pm).
We acknowledge that the North York community is diverse and our clinic has staff that can communicate in some languages other than English. However, English is our clinic’s primary language of operation and communication. We cannot always guarantee that a physician or NP who speaks a language other than English will be available, and in these cases it is the patient’s responsibility to bring an interpreter to their appointment.
We acknowledge that there is a family doctor shortage in Ontario. We often have a high volume of new enrolments, but are limited by how many applications we can process each week. You will be placed in the queue to schedule your first appointment (meet and greet). Before the first appointment, Compass Medical Clinic is not responsible for the patient’s care. After the first appointment, the patient may schedule appointments as needed. Please DO NOT contact us about how long the wait time is. If there is an issue with your enrolment form, we will contact you and your place in the queue will not be affected.
I am aware that Compass Medical Clinic is located in Toronto, Ontario
I understand that I must complete a separate form for each individual that is 16 years old or older.
By signing below, I hereby acknowledge that I have completely read and fully understand the policies of Compass Medical Clinic outlined above (four policies total).
Today's Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Please fill in the fields below as part of your enrolment to Compass Medical Clinic. Required fields are marked with a red star.
I would like to register with:
Please be advised that there may be a 2-4 month wait time for the initial meet and greet appointment
Name

First NameMiddle NameLast Name
Date of Birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Sex
Mailing Address

Street No. and Name or P.O. Box

Apartment Number

CityState / Province

Postal Code
Residence Address
Residence Address

Apartment Number

Street No. and Name or Lot, Concession and Township

CityState / Province

Postal Code
Please send notices from the doctor's office to me by:
Email Address:
example@example.com
Health Card Number
Version Code
The two letters after the health card number
I would also like to enroll my child (under 16) or a dependent adult with the doctor
Dependent 1

First NameSecond NameLast Name
Health Number
Version Code
Sex
Date of Birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
I am this person’s
Mailing Address
Mailing Address

Apartment Number

Street No. and Name or P.O. Box

City/TownState / Province

Postal Code
Residence Address
Residence Address

Apartment Number

Street No. and Name

City/TownState / Province

Postal Code
I would like to enroll another dependent with the family doctor
Dependent 2

First NameSecond NameLast Name
Health Number
Version Code
Date of Birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Sex
I am this person’s
Mailing Address
Mailing Address

Apartment Number

Street No. and Name or P.O. Box

City/TownState / Province

Postal Code
Residence Address
Residence Address

Apartment Number

Street No. and Name

City/TownState / Province

Postal Code
Section 3 – Signature

I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.
I am signing on behalf of (check all that apply)
I declare that the patient(s) named does/do not have a family physician due to one or more of the following reasons (check all that apply):
My Last Name
My First Name
Signature
Today's Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Home Telephone Number
Format: (000) 000-0000.
Work Telephone Number/Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?

Other
Should be Empty:

Patient Enrolment and Consent to Release Personal Health Information

Before completing the form below, please review the following policy items of Compass Medical Clinic. Your understanding and agreement to these items is necessary before beginning our enrolment process.

Please fill in the fields below as part of your enrolment to Compass Medical Clinic. Required fields are marked with a red star.

Section 3 – Signature