First Name*

Last Name*

Date of Birth* (YYYY-MM-DD)

Gender*
MaleFemaleOther

Health Card Number (with version code)*

Expiry Date (YYYY-MM-DD)

Upload Health Card Photo*

Street Address*

Unit #

City*

Province*

Postal Code*

Phone Number*

Email*

Current Family Physician (if applicable)

Family Physician You Wish to Register With

Current Medications

Allergies

Referred By

Pharmacy Name*

Pharmacy Street Address*

Unit #

City*

Province*

Postal Code*

Emergency Contact Name*

Relationship*

Emergency Contact Phone*

Preferred Method of Contact*
PhoneEmailSMS

Communication Consent*
I consent to receive communications about appointments and health services.

Additional Notes (Optional)