Patient Registration

Last Name *

First Name *

Date of Birth *

(Year/Month/Day e.g. 1923/APR/1)

Health Card (example: xxxxx-xxxxx) *

Health Card Version Code (Eg VX, MH ect) *

Address *

Apt *

City *

Postal Code *

Dropdown *

Phone Number *

Secondary Phone *

Email Address *

Reason for Consultation *

Preferred Pharmacy (Ex. Shoppers Parkwoods, Costco Warden, etc) *