Patient Enrolment and Consent to Release Personal Health Information
A separate form must be completed for each patient that is 16 years old or older.
Before completing this form, please review the following policy items of Canadian Family Clinic. Your understanding and agreement to these items is necessary before beginning our enrolment process.
Our physicians and nurse practitioners (NPs) work closely as a team to deliver comprehensive care. Both our physicians and NPs review medical concerns and test results. However, you may often be able to secure an appointment with one of our nurse practitioners earlier than with a physician.
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I understand that Canadian Family Clinic is a team-based practice and I am comfortable having appointments with either physicians or NPs, as appropriate.
Our administrative team is dedicated to meeting your needs as quickly as possible. To ensure the most efficient service, email is our primary method of communication. We monitor and reply to messages during our regular business hours, Monday through Friday from 9:00 am to 5:00 pm.
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I understand that email is Canadian Family Clinic’s primary method of communication and I consent to receiving clinic notices via email.
We acknowledge the diversity of North York and are fortunate to have some team members who can speak languages other than English. However, English is our primary language of communication and we cannot guarantee that you will be matched with a physician or NP who speaks your preferred language. Patients requiring language translation are responsible for bringing an interpreter to their appointments to ensure clear communication regarding their care.
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I understand that English is the primary language of communication and operation at Canadian Family Clinic.
Although our team works diligently to process a high volume of new patient applications, we are limited in how many we can intake each week. After submitting your form, you will join our queue for a 'meet and greet' appointment. Please note that Canadian Family Clinic does not assume responsibility for your medical care until this first appointment has taken place. After the first appointment, you may schedule appointments as needed. Please DO NOT contact us about how long the wait time is. If there is an issue with your enrolment form, we will contact you and your position in the queue will not be affected.
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I understand that Canadian Family Clinic will place my application in a queue and will contact me to schedule my first appointment.
By signing below, I hereby acknowledge that I have completely read and fully understand the policies of Canadian Family Clinic outlined above.
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Today's Date
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/
Year
/
Month
Day
Date
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Please fill in the fields below as part of your enrolment at Canadian Family Clinic.
Required fields are marked with a red star.
Name
*
First Name
Middle Name
Last Name
Date of Birth (yyyy/mm/dd)
*
/
Year
/
Month
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
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
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
*
-
Month
-
Day
Year
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
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
Please take some time to review the Patient Commitment, Consent to Release Personal Health Information, and Cancellation Conditions below.
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.
*
Yes
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
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
My Name
*
First Name
Last Name
Signature
*
Today's Date
*
/
Year
/
Month
Day
Date
Home/Preferred Telephone Number
*
Format: (000) 000-0000.
Cell Phone Number/Work Telephone Number
Format: (000) 000-0000.
How did you hear about us?
Social Media (e.g. Facebook, Instagram, etc.)
Internet (e.g. Google)
Other
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