New-patient registration

Send a registration request for clinic review.

Registration is not guaranteed.

Submitting this form does not confirm acceptance, a physician assignment, or an appointment.

01 Primary patient

First name *

Last name *

Date of birth *

Phone *

Email *

We will contact you by phone about your registration.

02 Health card

Enter the 10-digit number and the one- or two-letter version code shown on the card.

Health card number *

Version code *

03 Home address

Street address *

Address line 2 optional

City *

Province *

Postal code *

04 Pharmacy optional

Provide a pharmacy only if you want it recorded with this request. The clinic has not designated a required pharmacy.

Pharmacy name

Pharmacy address

05 Additional family members optional

Add up to eight people to the same household request. Each person is stored safely with the primary registration.

06 Final details

Additional information optional

Include only information that helps clinic staff review this registration request.

Your request is saved only after you see a confirmation page.