New Patient Form

  • Simon Fraser Medical Centre - New Patient Application Please email to: natasha@polycanhealthcentre.com

    To book appointments, please email above or TEXT 604 260 4040

  • How did you hear about our clinic?
  • Date of Birth YYYYMMDD
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have any ICBC or WCB Claims?
  •  
  • Should be Empty: