First Name*

Last Name*

Date of Birth* (YYYY-MM-DD)

Gender*
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Health Card Number (with version code)*

Expiry Date (YYYY-MM-DD)

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)