Request for New Family Doctor Form
Requests are processed on a first-come first-serve policy or those with significant primary care needs or from high need postal codes as per guidelines.
Patient Details:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number. Cell phone preferred
Format: (000) 000-0000.
Date of Birth
-
Year
-
Month
Day
Please Enter Your Date of Birth
Healthcard Number
*
Please enter your OHIP Number and validation code eg 987 654 3211 XY
Healthcard Expiry
*
-
Year
-
Month
Day
Year-Month-Day
Gender
Male
Female
Non-Binary
Prefer not to say
How did you hear about us?
Please Select
Friend/Family
Web search
Government Organization
Health Care Connect
Other
Other - Please describe
Physician(s) Requested - Please note we cannot guarantee specific physician availability. Check as many as you would willing to see.
*
No Preference
Keziah Emekeme MN, NP-PHC
Dr. Alex Xu
Relavent Details:
I.E - "Family member of existing patient John Smith", "Speak only Farsi", "will only accept female Physician" etc
Do you currently have a Family Doctor?
Yes
No
When was the last time you saw a Family Physician not including walk-in/urgent care?
Within 1 month
1 - 6 months
6 months - 2 years
>2 years ago.
Have you been admitted to a hospital in the last 2 months?
Yes
No
Please provide the Name, Date of Birth, Phone Number and Healthcard Number of Family Members In Your Household Requesting a new Family Doctor
Submit
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