New Patient Enrolment Form
Please complete a separate form for each patient that is 16 years old or older, unless you have a signed power of attorney document.
I understand that Canadian Family Clinic is physically located in Toronto, Ontario, but offers virtual care options to all Ontario residents.
*
Yes
Name
*
First Name
Middle Name
Last Name
Date of Birth (yyyy/mm/dd)
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Sex
*
M
F
Mailing Address
Street Address (e.g. 123 Example Road)
Apartment or Unit Number (if applicable)
City/Town
State / Province
Postal Code
Residence Address:
Is the same as mailing address
Is not the same as mailing address
Residence Address
Street Address
Apartment or Unit Number (if applicable)
City/Town
State / Province
Postal Code
Email Address:
*
example@example.com
Health Card Number
*
10 digits long, do not include dashes
Version Code
*
The two letters after the health card number
Home/Preferred Telephone Number
*
Format: (000) 000-0000.
Cell Phone Number/Work Telephone Number
Format: (000) 000-0000.
I prefer to be contacted by:
Email
Phone Call
I want to enrol my child(ren) under 16 and/or dependent adult(s)
*
Yes
No
Dependent 1
*
First Name
Middle Name
Last Name
Health Number
*
10 digits long
Version Code
*
The two letters after the health card number.
Sex
*
M
F
Date of Birth
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
I am this person's
*
Parent
Legal guardian
Attorney for personal care
Mailing Address
Same as above
Not the same as above
Mailing Address
*
Street Address
Apartment or Unit Number (if applicable)
City
State / Province
Postal / Zip Code
Residence Address
Same as above
Not the same as above
Residence Address
Street Address
Apartment or Unit Number (if applicable)
City
State / Province
Postal / Zip Code
I would like to enroll another dependent
*
Yes
No
Dependent 2
*
First Name
Middle Name
Last Name
Health Number
*
10 digits long
Version Code
*
the two letters after the health card number
Date of Birth
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Sex
*
M
F
I am this person's
*
Parent
Legal guardian
Attorney for personal care
Mailing Address
Same as above
Not the same as above
Mailing Address
*
Street Address
Apartment or Unit Number (if applicable)
City
State / Province
Postal / Zip Code
Residence Address
Same as above
Not the same as above
Residence Address
Street Address
Apartment or Unit Number (if applicable)
City
State / Province
Postal / Zip Code
Back
Next
Consent and Signature
I declare that the patient(s) named does/do not have a family physician due to one or more of the following reasons (check all that apply):
*
Family physician moved to another community
Patient moved to another community
Family physician is no longer available due to illness or retirement
Family physician is no longer available due to change of medical practice
Patient has not had, or felt the need for a family physician up until now
I am signing on behalf of (check all that apply)
*
Myself
Child(ren) under the age of 16
Dependent adult(s) for whom I have a power of attorney for personal care
My Name
*
First Name
Last Name
Signature
By signing below, I hereby acknowledge that I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.
*
Today's Date
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
How did you hear about us?
Social Media (e.g. Facebook, Instagram, etc.)
Internet Search (e.g. Google)
Word of Mouth
Other
Do you have any preferences?
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