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
Child/Dependent #1
Child/Dependent #1 - Name
First Name
Middle
Last Name
I am this person's
parent
legal guardian
attorney for personal care
Sex
Male
Female
Date of Birth (yyyy-mm-dd)
-
Year
-
Month
Day
Date
Health Card Number
10 digit number
Health Card Version Code
Last 2 letters
Mailing Address Same as Section 1?
Yes
No
Mailing - Street No. and Name
*
Mailing - Apartment #
Mailing - City/Town
*
Mailing - Postal Code
*
Residence Address Same as Section 1?
Yes
No
Residence - Street No. and Name
*
Residence - Apartment #
Residence - City/Town
*
Residence - Postal Code
*
Child/Dependent #2
Child/Dependent #2 - Name
First Name
Middle Name
Last Name
I am this person's
parent
legal guardian
attorney for personal care
Sex
Male
Female
Date of Birth (yyyy-mm-dd)
-
Year
-
Month
Day
Health Card Number
10 digit number
Health Card Version Code
Last 2 letters
Mailing Address Same as Section 1?
Yes
No
Mailing - Street No. and Name
*
Mailing - Apartment #
Mailing - City/Town
*
Mailing - Postal Code
*
Residence Address Same as Section 1?
Yes
No
Residence - Street No. and Name
*
Residence - Apartment #
Residence - City/Town
*
Residence - Postal Code
*
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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
*
Date
*
-
Year
-
Month
Day
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