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Patient Registration

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NEW PATIENT FORM

Patient Information:
First Name:
Last Name:
Name as it appears on the Health Card:
(if different from above)
Address:
Telephone Number:
Email Address:
Date of Birth (DD/MM/YYY):
Health Card Number:

Gender:  

Health Card Expiry Date (DD/MM/YYY):
Health Card Version Code:

Are you the main applicant?

If No, Name of Main Applicant:  

Relationship to main Applicant:  

Last Family Physician Information:

Name of Physician:

Address:

Date of Last Visit (DD/MM/YYY):

Please List Medical Problems:
Current Medications:
Allergies:
Best way to contact you:
   
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Yorkdale Medical Clinic, 11685 Yonge St., Unit A103, Richmond Hill, ON L4E 0K7
T: (905) 770-9057 F: (905) 917-0215