Patient Enrolment and Consent to Release Personal Health Information
Section 1 - I want to enrol myself with family physician, Dr. A. Smith.
Name
*
First Name
Middle Name
Last Name
Date of Birth (yyyy/mm/dd)
*
 /
Year
 /
Month
Day
1
Sex
*
Male
Female
Email
*
Home Phone
*
Alternate Phone
Street No. and Name
Apartment #
City/Town
Postal Code
Health Card Number
10 digit number
Health Card Version Code
Last two letters
Section 2 - I want to enrol my child(ren) under 16 and/or dependent adult(s) with family physician, Dr. A. Smith.
Number of children/dependents
*
None
One child/dependent
Two children/dependents
Child/Dependent #1
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Child/Dependent #1 - Name
First Name
Middle
Last Name
I am this person's
parent
legal guardian
attorney for personal care
Sex
Male
Female
Date of Birth (yyyy/mm/dd)
 /
Year
 /
Month
Day
Date
Health Card Number
10 digit number
Health Card Version Code
Last 2 letters
Child/Dependent #2
Â
Child/Dependent #2 - Name
First Name
Middle Name
Last Name
I am this person's
parent
legal guardian
attorney for personal care
Sex
Male
Female
Date of Birth (yyyy/mm/dd)
 /
Year
 /
Month
Day
2
Health Card Number
10 digit number
Health Card Version Code
Last 2 letters
Collapse Stopper
Â
Section 3 - Signature
I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions seen below. 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.
I am signing on behalf of (check all that apply):
*
myself
child(ren)
dependent adult(s)
Signature
*
Date
*
 -
Year
 -
Month
Day
3
Submit
Should be Empty: