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Registration Form

Registration Form

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PATIENT INFORMATION
MEDICAL HISTORY

Today’s date: ×

Date & Time of Appointment ×

Location of Appointment*

Markham

Scarborough

North York

Last Name

First Name

Date of birth ×

Male

Female

Address

Province

Postal Code

Home Phone

Cell phone

Email Address

Health Card

ALLERGIES ( Please type “none” if not applicable )

Version Code (two letters on the OHIP card)

CURRENT MEDICATION ( Please type “none” if not applicable )

Are you a Visitor or International Student? Please specify and provide Out of Province Health Card information if applicable. (Quebec health cards are not accepted)

High Blood Pressure*

Yes

Heart Disease*

Yes

Diabetes*

Yes

Asthma*

Yes

High Cholesterol*

Yes

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Our mission is to offer the upmost professional and personal care to you and your loved ones. We are dedicated to delivering excellent and comprehensive medical care in a supportive, inclusive and family-centered environment.

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