Email Address *

Last Name (As it appears on Health Card)*

First Name (As it appears on Health Card)*

Date of Birth *

Health Card Number(Optional)

Phone (Cell)*

Phone (Home)*

Current Address*


Postal Code*
I understand that the clinic may attempt to contact the patient regarding patient health matters by phone, text, email, or mail based on information provided above.*

I hereby agree that the above information provided is accurate, up to date, and that it is ultimately My Responsibility to return to the clinic, regardless of whether or not I have been contacted by the clinic, in order to ensure that I follow up on my results for any investigation (such as X-Ray, Ultrasound, Blood tests, Specialist referrals etc.).*

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