Patient Registration

Submit a new patient registration request online.

This form helps our clinic review your information and determine the next steps for patient intake. Please complete the details as accurately as possible so our team can follow up with you.

First Name * Last Name * Email * Phone * Date of Birth *

Health Card Number * Version Code *

Street Address * Address Line 2 City * Province * ZIP / Postal Code *

Preferred Pharmacy Preferred Pharmacy Address

Preferred Doctor No doctors available right now. You can still submit your registration request for clinic review.

Add any spouse, child, or dependent you want included in this same registration request. Each family member can have their own contact, health card, address, and pharmacy details saved in the same household record.

No additional family members added yet.

Message (Optional) I consent to clinic follow-up. I consent to waitlist communication.

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Submit a new patient registration request online.

Patient Information

Health Information

Address Information

Preferred Pharmacy

Registration Preferences

Additional Family Members

Family Member

Additional Information