Patient Registration Form

Please fill out all mandatory fields marked with red * and submit the form by clicking the Submit button below.
This is a secured form, so collected information will be stored and used for medical records and services puposes.
Each person must register separately including infants and children.
If you have any questions or require assistance, please contact the clinic at 1-905-605-8444.

1. Patient Information:

If under 18, enter the name of the Parent or legal Guardian and register separately afterwards to link your profile to your child:

Name of Parent or Legal Guardian *

2. Health Card Information

Most patients are covered under OHIP program and some have additional coverage under private insurance.
We still can provide services for you at our Clinic if you are a refugee registered under the IFHP program, or a Veteran or a member of the armed forces, RCMP or a pilot, or have WSIB or travel insurance.
Call us if you need help determining your eligibility, at 1-905-605-8444.

Health Card Number *

Version Code *

Card Type *

Green Red

Private Insurance *

Yes No

3. Patient Medical Background and Lifestyle

Heart Disease (Specify) *

Cancer (Specify) *

Hospitalization/Surgeries (Specify) *

List of Medication (Regular) *

Stroke/Clot (Specify) *

Allergies (Specify) *

Recent Immunization (Specify) *

Family Disease (Critical) *

APPOINTMENT PREFERENCE

TIME *

MORNING (9 AM - NOON) AFTERNOON (NOON - 4 PM) EVENING (4 PM - 8 PM)

MONTH *

DAY (DD) *

Acknowledge *

Agree

By submitting this form, you agree that your private and medical information will be stored, utilized and shared with other healthcare professionals in order to provide medical services by Ansley Grove Medical Centre, physicians and staff, for you or for your child or a person under your care; in accordance with relevant regulations and privacy legislations.