• 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.

  • 1. 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.
    2. To provide the most efficient service, email is our primary method of communication. Our administrative team monitors and responds to messages during regular business hours, Monday through Friday, from 9:00 AM to 5:00 PM.
    3. English is our primary language. While some staff speak other languages, matching with a multi-lingual provider is not guaranteed. Patients requiring language translation are responsible for bringing an interpreter to their appointments to ensure clear communication regarding their care.
    4. 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.

  • Today's Date*
     / /
    4 digit year, 2 digit month, 2 digit day

  • Please fill in the fields below as part of your enrolment at Canadian Family Clinic.

    Required fields are marked with a red star.
  • Date of Birth (yyyy/mm/dd)*
     / /
    4 digit year, 2 digit month, 2 digit day
  • Sex*
  • Residence Address:*
  • I want to enrol my child(ren) under 16 and/or dependent adult(s)*
  • Sex*
  • Date of Birth *
     / /
    4 digit year, 2 digit month, 2 digit day
  • I am this person's*
  • Mailing Address*
  • Residence Address*
  • I would like to enroll another dependent*
  • Date of Birth*
     / /
    4 digit year, 2 digit month, 2 digit day
  • Sex*
  • I am this person's*
  • Mailing Address*
  • Residence Address*

  • Consent and Signature

    Please take some time to review the Patient Commitment, Consent to Release Personal Health Information, and Cancellation Conditions below.
  • Image field 155
  • I am signing on behalf of (check all that apply)*
  • 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):*
  • Today's Date*
     / /
    4 digit year, 2 digit month, 2 digit day
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?
  •  
  • Should be Empty: