Northwestern Ontario Registration Form

Northwestern Ontario Registration Form
Foria Clinic is providing free services to trans and nonbinary people in Northwestern Ontario and Thunder Bay through a partnership with NorWest CHC. Sign up here for virtual gender-affirming care, including hormone therapy and surgery assessments.

If you are interested in registering for these virtual services, click "Next" below to fill out and submit the registration form. You will receive a confirmation email afterwards with a private booking link where you can book an appointment with a Foria nurse practitioner.

If you prefer in-person care at the NorWest Thunder Bay Site, please go to the registration form at the NorWest website, under 2SLGBTIAQ programs.

If you choose to complete this registration, your personal information will be securely collected and shared between Foria Clinic and NorWest CHC, in accordance with the Personal Health Information Protection Act (PHIPA) of Ontario.

Eligibility
Do you live in Northwestern Ontario (includes the districts of Kenora, Rainy River and Thunder Bay)?*

YesNo
Free services are only available to those living in Northwestern Ontario.*

I understand that I do not meet the regional criteria to book an appointment.

Registration
Legal Name*

First NameLast Name
Preferred Name
Pronouns
Health Card Number*
Please include the 10 digits and 2 letters. If you do not have OHIP, please write "N/A".
Date of Birth*

YearMonthDay
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code (Please enter values without spaces or hyphens, e.g. A1B2C3)