Registration Form for Family Practice at Lifeline Medical Clinic - Oakville
You will be contacted over email once we process your registration
Name
*
First Name
Last Name
Sex Assigned at Birth
*
Please Select
Male
Female
Intersex
Transgender
Undefined
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
OHIP Card Number without Version Code
*
Version Code
*
I consent to receive text messages (SMS)
*
Yes
No
I consent to receive emails
*
Yes
No
Please list any allergies you may have or leave as "NKDA" if you do not have any known allergies:
*
Please list any relevant medical history or existing medical conditions or leave as "healthy" if you do not have any known conditions:
*
Please list any relevant surgical or hospitalization history or leave as "Never" if you've never been surgically treated / hospitalized:
*
Please list any medications you are taking or leave as "None" if you are not on any medications:
*
Submit
Should be Empty: