Consent to Enroll

Consent to Enroll

By completing this form, you are agreeing to enrol in Dr. Ogugua Vann's practice at Magnolia Health Centre, please complete one form per family member.
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
OHIP Health Insurance Number (HIN)
Acknowledgement and Consent

By signing below, I acknowledge and agree to the following terms of enrolment:

I agree to contact this family doctor's office first for medical advice or treatment, unless I have an emergency or am traveling away from home. I consent to my family doctor and the Ministry of Health exchanging my enrolment information. I also authorize the Ministry to release specific information to my doctor, including dates of immunizations, preventive care screenings, and details of primary care services I receive from other doctors. If available, I permit my basic personal information to be shared with the Telephone Health Advisory Service. I will notify my doctor's office if I move or change my contact details. I understand that I can enroll with a different doctor after six weeks, but I agree not to change my enrolled doctor more than twice a year.
Signature (by typing your full name, you acknowledge this is your digital signature)
Should be Empty: