New Patient Registration Form

Name

Last Name

Phone Number

Email Address

Gender GenderMaleFemaleChoose not to disclose

Emergency Contact Person

Do you have a valid government-issued Health Card? Do you have a valid government-issued Health Card? Yes No

How did you hear about us? How did you hear about us?Referral from someoneGoogle SearchOthers

I am filling this Registration Form I am filling this Registration Form As myself As a guardian on behalf of a minor child As a guardian of an adult under the Dependent Adults Act on his/her behalf As a designated agent of an adult under the Personal Directives Act on their behalf As an authorized relative of a patient as defined in the Mental Health Act