Patient Enrolment and Consent to Release Personal Health Information
Please complete a separate form for each patient that is 16 years old or more.
Before completing the form below, please review the following policy items of Compass Medical Clinic. Your understanding and agreement to these items is necessary before beginning our enrolment process.
Our physicians work together with nurse practitioners (NPs) to deliver comprehensive care. All medical concerns are reviewed by our physicians, however, you may often be able to secure an appointment with one of our nurse practitioners earlier than with your physician.
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I understand that Compass Medical Clinic is a team-based practice and I am comfortable having appointments with either physicians or NPs, as appropriate.
Our administrative team works hard to meet our patients’ needs in a timely manner. To optimize this, email is our primary means of communication between patients and our clinic staff. We reply to emails during our business hours (Monday to Friday, 9:00am to 5:00pm).
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I understand that email is Compass Medical Clinic’s primary means of communication.
We acknowledge that the North York community is diverse and our clinic has staff that can communicate in some languages other than English. However, English is our clinic’s primary language of operation and communication. We cannot always guarantee that a physician or NP who speaks a language other than English will be available, and in these cases it is the patient’s responsibility to bring an interpreter to their appointment.
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I understand that English is the primary language of communication at Compass Medical Clinic.
We acknowledge that there is a family doctor shortage in Ontario. We often have a high volume of new enrolments, but are limited by how many applications we can process each week. You will be placed in the queue to schedule your first appointment (meet and greet). Before the first appointment, Compass Medical Clinic is not responsible for the patient’s care. After the first appointment, the patient may schedule appointments as needed. Please DO NOT contact us about how long the wait time is. If there is an issue with your enrolment form, we will contact you and your place in the queue will not be affected.
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I understand that Compass Medical Clinic will place my application in a queue and Compass Medical Clinic will contact me to schedule my first appointment.
I am aware that Compass Medical Clinic is located in Toronto, Ontario
Yes
I understand that I must complete a separate form for each individual that is 16 years old or older.
Yes
By signing below, I hereby acknowledge that I have completely read and fully understand the policies of Compass Medical Clinic outlined above (four policies total).
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Today's Date
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/
Year
/
Month
Day
Date
Please fill in the fields below as part of your enrolment to Compass Medical Clinic. Required fields are marked with a red star.
I would like to register with:
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Please Select
First Available Family Doctor
Dr. Victor Liao
Dr. Grace Liao
I am a former patient of Dr. Michael Wyman
Please be advised that there may be a 2-4 month wait time for the initial meet and greet appointment
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Year
/
Month
Day
Date
Sex
*
M
F
Mailing Address
*
Street No. and Name or P.O. Box
Apartment Number
City
State / Province
Postal Code
Residence Address
*
Same as mailing address
Not the same as mailing address
Residence Address
*
Apartment Number
Street No. and Name or Lot, Concession and Township
City
State / Province
Postal Code
Please send notices from the doctor's office to me by:
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email (default)
Email Address:
*
example@example.com
Health Card Number
*
Version Code
*
The two letters after the health card number
I would also like to enroll my child (under 16) or a dependent adult with the doctor
*
Yes
No
Dependent 1
*
First Name
Second Name
Last Name
Health Number
*
Version Code
*
Sex
*
M
F
Date of Birth
*
/
Year
/
Month
Day
Date
I am this person’s
*
parent
legal guardian
attorney for personal care
Mailing Address
*
Same as above
Not the same as above
Mailing Address
*
Apartment Number
Street No. and Name or P.O. Box
City/Town
State / Province
Postal Code
Residence Address
*
Same as above
Not the same as above
Residence Address
*
Apartment Number
Street No. and Name
City/Town
State / Province
Postal Code
I would like to enroll another dependent with the family doctor
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Yes
No
Dependent 2
*
First Name
Second Name
Last Name
Health Number
*
Version Code
*
Date of Birth
*
/
Year
/
Month
Day
Date
Sex
*
M
F
I am this person’s
*
parent
legal guardian
attorney for personal care
Mailing Address
*
Same as above
Not the same as above
Mailing Address
*
Apartment Number
Street No. and Name or P.O. Box
City/Town
State / Province
Postal Code
Residence Address
*
Same as above
Not the same as above
Residence Address
*
Apartment Number
Street No. and Name
City/Town
State / Province
Postal Code
Section 3 – Signature
I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.
Preview PDF
Submit
I am signing on behalf of (check all that apply)
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myself
child(ren)
dependent adult(s)
My Last Name
*
My First Name
*
Signature
*
Today's Date
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/
Year
/
Month
Day
Date
Home Telephone Number
*
Work Telephone Number/Cell Phone Number
Please enter a valid phone number.
How did you hear about us?
Social Media (e.g. Facebook, Instagram, etc.)
Internet (e.g. Google)
Other
Should be Empty: