Register New Patient (2)

New Patient Demographic Form

Today's Date *

Are You Looking a Family Doctor? *

Patient Name (First and Last Name) *

Gender *

Date of Birth *

Healthcare Number (Give to Staff at Desk)

Address *

City *

Province *

Postal Code *

Email

Phone Number *

+1

Emergency Contact Phone Number

+1

Emergency Contact Name *

Relationship

This clinic has zero tolerance for harassment and foul language by staff. By signing this form, you agree to the clinic's Policy.

Heidi Patient Informed Consent

Before your appointment, we want to inform you that we use a note-taking tool, Heidi, to enhance our consultations. Your consent is essential, and we will handle your information carefully to improve your healthcare experience. You can choose to opt out of Heidi during your consultation.

Please acknowledge by checking the boxes: *

I have been informed about the use of Heidi and its purpose.

I understand how my information will be handled, stored, and protected.

I agree my clinician can use Heidi to assist with documenting my consultation.

I can withdraw my consent at any time, and it will not affect the quality of care I receive.

Signature *

SERVICES

CONTACT INFO

New Patient Demographic Form