Dr. Fortowsky Patient Enrolment Form

Patient Enrolment and Consent to Release Personal Health Information
Section 1 - I want to enrol myself with family physician, Dr. Grant Fortowsky *

Yes No

Personal Enrolment
Name *

First Name Middle Name Last Name
Date of Birth (yyyy-mm-dd) *

Year Month Day
Sex *

Male Female
Health Card Number *
10 digit number
Health Card Version Code *
Last two letters
Email *
Would you like to be registered for a Medeo Health Account? Medeo Health is the Online Booking, Messaging and Reminder platform for the Amherstburg Family Health Team.

Yes No
Mailing - Street No. and Name *
Mailing - Apartment #
Mailing - City/Town *
Mailing - Postal Code *
Residence Address same as Mailing Address? *

Yes No
Residence - Street No. and Name *
Residence - Apartment #
Residence - City/Town *
Residence - Postal Code *

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Section 2 - I want to enrol my child(ren) under 16 and/or dependent adult(s) with family physician, Dr. Grant Fortowsky.
Number of children/dependents *

None One child/dependent Two children/dependents

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Section 3 - Signature

I have read and agree to the Consent to Release Personal Health Information and the Cancellation Conditions seen below. 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): *

myself child(ren) dependent adult(s)
Name *

First Name Last Name
Home Phone *
Alternate Phone
Signature *

Clear
Date *

Year Month Day
Should be Empty:

Patient Enrolment and Consent to Release Personal Health Information