MyCare 365 Registration Form

MyCare 365

INFO@MYCARE365.CA

www.mycare365.ca
New Patient Registration

Please fill in the form below
Registration Date and Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Health Card
Patient Name*

First NameLast Name
Gender*

MaleFemalePrefer not to sayNot listed
Date of Birth*

MonthDayYear
Phone Number*
Email *
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Is the patient younger than 18?*

YesNo
Parent Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Do you have a family physician?

If yes, please fill the form below, otherwise leave it blank
Family Doctor Name

First NameLast Name
Family Doctor Phone Number
Preferred Pharmacy*
Name and address
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Fax Number*
Please enter a valid phone number.
Health History
Reason for Registration*
Additional Notes
Taking any medications, currently?*

YesNo
Please list them here (Name, dose, frequency)
Which MyCare Plan would you be interested in?
MyCare Now*
Yes or no
MyCare Plus +*
Yes or No
Signature*

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My Care 365 Disclaimer:

At My Care 365 we are bound by human rights legislation as well as CNO Code of Ethics and Professionalism and will accept patients "without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). My Care 365 has enforced a wait list due to resource limitations and to ensure comprehensive care to each individual in a timely manner. We will accept new patients, on the prinicple of first-come, first-served. However, we do retain the right to refuse acceptance for legitimate reasons.
Should be Empty:

New Patient Registration

Health Card

Do you have a family physician?

Health History

Which MyCare Plan would you be interested in?