New Patient Registration

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General Information General

Medical Information Medical

First Name*

Last Name*

Date of Birth*

Sex Assigned at Birth*

Email Address*

Phone Number

Street Address

City

Postal Code

Username*

Create Password*

Confirm Password*

Name of Primary Care Provider

Ontario Health Card Number*

Do you use alcohol?*

Yes No

Explain Alcohol Use*

Do you smoke cigarettes?*

Yes No

Explain Cigarette Smoking*

Do you use recreational drugs?*

Yes No

Explain Recreational Drug Use*

Allergies

Current Medications

Do You Have Third Party Drug Insurance?*

Yes No

Insurance Provider *

Policy Number *

Member Id

Upload Insurance Card Front*

Drag Drop Here Or Click To Select a File

Click To Change

Upload Insurance Card Back*

Drag Drop Here Or Click To Select a File

Click To Change

Optional Notes