PATIENT WAITING LIST

PATIENT WAITING LIST REGISTRATION POLICY

1. Only one form per patient, (Please DO NOT submit multiple times. Thank You)

2. Please do not call our office for registration updates.

3. Filling in our Patient Waiting List (PWL) does not guarantee registration in the clinic.

First Name: *

Last Name *

Street Address (Ontario ONLY) *

Unit / Apartment Number (if Applicable)

City (Ontario ONLY) *

Postal Code *

Phone Number *

Enter your email address *

Date of Birth *

Gender *

Health Card Number (Ontario ONLY) *

Health Card Version (Ontario ONLY) *

Health Card Expiry Date *

Do you currently have a Family Doctor in Ottawa? *

Yes

Comments

Consent to use any form of electronic communication *

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